THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 

LOS  ANGELES 

GIFT  OF 


SAN  FRANCISCO 
COUNTY  MEDICAL  SOCIETY 


I. 

THE    MECHANISM   OF    DISLOCATIONS 
AND  FRACTURE  OF  THE  HIP 

II. 

LITHOLAPAXY;   OR,  RAPID   LITHOTRITY 
WITH   EVACUATION 


BY 

HENRY   JACOB    BIGELOW 

A.M.,  M.D.,  LL.D. 

MEMBKR    OF   THE   MASSACHUSETTS   MEDICAL    SOCIETY  ;     EMERITUS    PKO- 
EESSOK    OP    SURGERY     IN     HARVARD    UNIVERSITY;     SURGEON    OB' 
THE     MASSACHUSETTS     GENERAL     HOSPITAL;     MEMBER     OF 
THE   AMERICAN    ACADEMY   OF    ARTS   AND   SCIENCES  ; 
MEMBER   OF   THE    BOSTON    SOCIETY   FOR    MEDI- 
CAL   improvement;     member    of    THE 
BOSTON      St)ClETY      OF      NATURAL 

history; 
foreign  honorary  member  of  the  clinical  society  of  london; 

MEMBRE    CORRESPONDANT    ETRANGER    DE     la    SOCIETY    DE    CHI- 

RURGIE    DE   PARIS;    MEMBRE    HONORAIRE    DE    LA    SOCIETE 

ANATOMIQUE    DE    PARIS  ;    MEMBRE    CORRESPONDANT 

DE  LA  SOCi:^TE  BIOLOGIQUE  DE  PARIS;    SOCIUS 

EXTRANEUS     SOCIETATIS     MEDIC.E    NOR- 

VEGICiE  ;     ETC.,   ETC. 


?Vmi 


« 


BOSTON 
LITTLE,  BROWN,  AND   COMPANY 

1900 


729 


University  Press  : 
John  Wilson  and  Son,  Cambridge,  U.S. A 


Biomedical 
Library 


THE  First  Part  of  this  volume  contains  Dr.  Bigelow's 
Treatise  on  the  Mechanism  of  Dislocations  and  Frac- 
ture of  the  Hip,  which  has  been  long  out  of  print.  The 
Papers  appended  thereto  comprise  his  other  contributions  to 
the  literature  of  these  subjects.  They  are  reproduced  with 
only  such  changes  of  the  original  text  as  their  author  had 
indicated  a  desire  to  have  made. 

The  Second  Part  includes  Dr.  Bigelow's  published  articles 
on  Rapid  Lithotrity,  arranged  in  chronological  order,  and 
unmodified  except  by  his  own  annotations. 

Boston,  1894. 


593274 

n      ■   ■ 


CONTENTS. 


part  £. 

THE  MECHANISM  OF   DISLOCATIONS  OF  THE  HIP. 

Page 

Introduction 3 

Abstract 4 

Dislocation  of  the  Hip       •     .  9 

The  Y  Ligament        1« 

Capsule  of  the  Hip 20 

Ligamentum  Teres 20 

Obturator  Internus  Muscle 21 

Other  Muscles 23 

General  Remarks  upon  Reduction 26 

Position  of  the  Patient  and  Surgeon 30 

The  Y  Ligament,  with  Reference  to  Reduction  and  to  Subse- 
quent Treatment 30 

How  the  Limb  is  to  be  Held 32 

Capsular  Orifice  to  be  Enlarged 32 

Fracture  of  the  Neck 34 

Flexion,  Extension,  Adduction,  Abduction,  and  Rotation     .     .  34 

Circumduction 35 

Regular  Dislocations 35 

Dislocation  upon  the  Dorsum  Ilii 35 

Signs 37 

Dorsal  Dislocation  between  the  Rotator  Muscles     .....  42 

Reduction  of  the  Dislocation  upon  the  Dorsum    ....  44 

Dorsal  below  the  Tendon 56 

Signs '5^ 

The  Mechanism  of  its  Production,  and  Cause  of  its  Irre- 

ducibility ^1 

Reduction ^4 


Vlll  CONTENTS. 

Regular  Dislocations,  —  continued.  Page 

Thyroid  and  Downward  Dislocations 66 

Thyroid 66 

Signs 67 

Vertical  Downward  Luxation 69 

Dislocations  near  the  Tuberosity  or  Perinseum 71 

Reduction 75 

Dislocation  upon  the  Pubes 80 

Dislocation  below  the  Anterior  Inferior  Spine  of  the  Ilium.  — 

Sub-spinous 82 

Reduction 84 

Anterior  Oblique  Dislocation 87 

Dislocations  in  which  the  Outer  Branch  of  the  Y  Ligament  is 

Broken.  —  Suprarspiuous 90 

Reduction 94 

Everted  Dorsal  Dislocation 94 

Reduction 96 

Irregular  Dislocations  in  which  the  Y  Ligament  is  wholly 

Broken 97 

Irregular  Upw^ard  Luxation 99 

Irregular  Downward  Luxation 100 

Reduction 101 

Special  Conditions  of  Dislocation 101 

Old  Dislocations  and  their  Reduction 101 

Dislocation  from  Hip  Disease 104 

Dislocation  of  the   Hip,  with   Fracture   of  the  Shaft  of  the 

Femur 105 

Spontaneous  Dislocation 106 

Fracture  of  the  Pelvis 108 

Fracture  of  the  Rim  of  the  Acetabulum 109 

Fracture  in  which  the  Head  of  the  Femur  is  driven  through 

the  Acetabulum Ill 

Asserted  Fracture  of  the  Acetabulum,  without  Crepitus,  from 

a  supposed  Impossibility  of  keeping  the  Femur  in  Place   .     .  112 

Fracture  of  other  Parts  of  the  Pelvis 113 

Angular  Extension 114 

On  Dislocation  of  the  Hip 118 


CONTENTS.  ix 


THE  MECHANISM  OF   FRACTURES   OF   THE 
NECK  OF   THE   FEMUR, 

Page 

Fracture  of  the  Neck  of  the  Femur 13iJ 

Impacted  Fracture  of  the  Base  of  the  Neck,  with  Eversiou  .     .  189 

Anatomical  Structure  of  the  Neck  of  the  Femur 141 

Rotation 142 

Shortening        142 

True  Neck 143 

Remarks 145 

Impacted  Fracture  of  the  Base  of  the  Neck,  with  Inversion      .  147 

Impacted  Fracture  of  the  Neck  of  the  Femur  near  the  Head   •  150 

Comminuted  Fracture  of  the  Trochanters  without  Impaction    .  154 

Fracture  of  the  Neck  of  the  Femur  resulting  in  False  Joint      .  155 

Crack  in  the  Neck  of  the  Femur .  156 

The  True  Neck  of  the  Femur  :  its  Structure  and  Pathol- 
ogy       158 

Anatomical  Structure  of  the  Neck  of  the  Femur 161 

True  Neck 162 

Pathology  :  Impacted  Fractures 167 

Posterior  Impacted  Fracture  of  the  Base  of  the  Cervix    .     .     .  167 

Impacted  Fracture  of  the  Head  of  the  Femur 170 

Impacted  Fracture  of  the  whole  Base  of  the  Cervix,  with  Inver- 
sion        172 

Unimpacted  Fractures 172 

Fracture  of  the  Small  Part  of  the  Cei'vix  of  the  Femur    .     .     .  172 

Comminuted  Fracture  of  the  Trochanters  and  Shaft    ....  172 

Treatment 173 

Fracture  of  the  Neck  of  the  Thigh  Bone 175 


CONTENTS. 


IPart  H. 

RAPID   LITHOTRITY,   WITH  EVACUATION. 

Pagk 

Rapid  Lithotrity 191 

Rapid  Lithotiuty,  with  Evacuation 229 

LiTHOLAPAXY 235 

LiTHOLAPAXY 242 

LiTHOLAPAXY     ; 254 

LiTHOLAPAXY 258 

LiTHOLAPAXY 261 

LiTHOLAPAXY;    OR    LiTHOTRITY    WITH   IMMEDIATE    EVACUATION  264 

LiTHOLAPAXY.       An    IMPROVED    EVACUATOR 274 

LiTHOLAPAXY 282 

De    LA    LiTHOLAPAXIE  :    OU    LiTHOTRITIE  AVEC    EVACUATION    IM- 
MEDIATE   EN    UNE    SEULE    SeAXCE 285 

Modern  Li'thotrity 296 

LiTHOLAPAXY 320 

Lithotrity,  with  Evacuaton 323 

A  Simplified  Evacuator  for  Litholapaxy 332 


Index       347 


PART    I. 


dislocatio:n^  akd  feacture  of 

THE    HIP. 


INTRODUCTION. 


Some  of  the  more  important  points  in  this  paper 
are  presented  in  the  following  abstract,  which  may 
serve  either  as  a  table  of  contents  or  as  a  list  of 
propositions  to  be  established  by  the  evidence  in 
the  text.  The  comparatively  few  published  autopsies 
of  dislocation  of  the  hip,  and  the  still  fewer  conclu- 
sive ones,  are  perhaps  insufficient  for  the  complete 
analysis  of  its  complicated  mechanism;  but  the  defi- 
cient evidence  may  in  a  great  measure  be  supplied 
by  experiments  upon  the  dead  subject,  where  the 
essential  conditions  are  identical  with  those  of  the 
living  and  etherized  patient,  although  the  contrary  has 
been  alleged.  The  views  here  advanced  may  also  be 
tested  by  the  light  they  throw  upon  reported  cases,  of 
which  I  have  carefully  examined  such  as  were  accessi- 
ble to  me.  If  still  deemed  inconclusive,  they  must  re- 
main in  doubt  until  established  or  confuted  by  further 
observation ,  but  in  the  mean  time  it  is  certain  that 
dislocated  hips  can  be  reduced  upon  the  principles  and 
by  the  rules  laid  down  and  explained  in  this  paper. 
After  reasonable  attention  to  the  subject,  I  confess 
that  I  can  find  no  explanation  so  satisfactory  as  that 
here  given. 


4  INTRODUCTION. 

ABSTRACT. 

The  points  which  were  new  to  science  in  the  first  edition  are  here  printed  in  italics. 

1.  The  anterior  part  of  the  capsule  of  the  hip  joint  is  a 
triangular  ligament  of  great  strength,  which,  when  well  devel- 
oped, exhibits  an  internal  and  external  fasciculus,  diverging 
like  the  branches  of  the  inverted  letter  Y.  It  rises  from  the 
anterior  inferior  spinous  process  of  the  ilium,  and  is  inserted 
into  nearly  the  entire  length  of  the  anterior  intertrochanteric 
line. 

2.  The  Y  ligament,  the  internal  obturator  muscle,  and  the 
capsule  subjacent  to  it,  are  alone  required  to  explain  the  usual 
phenomena  of  the  regular  luxations. 

3.  The  regular  dislocations  are  those  in  which  one  or  loth 
tranches  of  the  Y  ligament  are  unbroken ;  and  their  signs  are 
constant. 

4.  The  irregular  dislocations  are  those  in  which  the  Y  liga- 
ment is  wholly  ruptured  ;  and  they  offer  no  constant  signs. 

5.  In  the  regular  dislocations  of  the  hip,  the  muscles  are  not 
essential  to  give  position  to  the  limb,  nor  desirable  as  aids  in  its 
reduction. 

6.  The  Y  ligament  will  alone  effect  reduction  and  explain  its 
phenomena,  a  part  of  those  connected  with  the  dorsal  dislocations 
excepted.  During  the  process  of  reduction,  this  ligarnent  should 
be  kept  constantly  in  mind. 

7.  The  rest  of  the  capsule,  except  perhaps  that  portion  beneath 
the  internal  obturator  tendon,  need  not  be  considered  in  reduction, 
if  the  capsular  orifice  is  large  enough  to  admit  the  head  of  the 
femur  easily. 


INTRODUCTION.  5 

8.  If  the  capsular  orifice  is  too  small  to  allow  easy  reduction, 
it  should  he  enlarged. 

9.  The  capsular  orifice  may  he  enlarged  at  will,  and  with 
impunity,  hy  circumduction  of  the  flexed  thigh. 

10.  Recent  dislocations  can  he  hest  reduced  hy  manipulation. 

11.  The  hasis  of  this  manipulation  is  flexion  of  the  thigh. 

12.  This  manipulation  is  efiicient  either  hy  one  method,  he- 
cause  it  relaxes  the  Y  ligainent,  or  hy  another  method,  hecause 
that  ligame7it,  remaining  tense,  is  a  fixed  point,  around  which 
the  head  of  the  femtir  revolves  near  the  socket. 

13.  TJie  further  manipulation  of  the  fiexed  thigh  may  he 
either  hy  traction  or  rotation. 

14.  The  dorsal  dislocation  owes  its  inversion  to  the  external 
hranch  of  the  Y  ligament. 

15.  The  so-called  ischiatic  dislocation  owes  nothing  what- 
ever of  its  character,  or  its  dijfflculty  of  reduction  hy  horizontal 
extension,  to  the  ischiatic  notch. 

16.  The  ischiatic  dislocation  is  hetter  named  dorsal  below 
the  tendon,  and  is  easily  redticed  hy  manipulation.  But  the 
term  "ischiatic"  might  hetter  he  suppressed.  It  is  the  dorsal 
dislocation  with  the  least  shortening. 

17.  TJie  flexion  of  the  thyroid  and  downward  dislocations  is 
due  to  the  Y  ligament,  which,  in  the  first,  also  everts  the  limh, 
until  the  trochanter  rests  upon  the  pelvis. 

18.  In  the  puhic  dislocation,  the  range  of  the  hone  upon  the 
puhes  is  limited  hy  this  ligament,  which,  in  the  suh-spinous  dis- 
location also,  hinds  the  neck  of  the  femur  to  the  pelvis. 

19.  In  the  dorsal  dislocation  with  eversion,  the  outer  hranch 
of  the  Y  ligament  is  ruptured.  In  the  ahsence  of  this  fulcrum, 
this  dislocation  may  need  pulleys  for  its  reduction. 


6  INTRODUCTION. 

20.  In  the  anterior  oblique  luxation,  the  head  of  the  hone  is 
hooked  over  the  entire  Y  ligament,  the  limb  being  then  necessarily 
oblique,  everted,  and  a  little  jlexed. 

21.  In  the  supraspinous  luxation,  the  head  of  the  femur  is 
equally  hooked  over  the  Y  ligament,  the  external  branch  of  which 
is  broken.     The  limb  may  then  be  fully  extended. 

22.  In  old  luxations,  the  period  during  which  reduction  is 
possible  is  determined  by  the  extent  of  the  obliteration  of  the 
socket,  the  strength  of  the  neck  of  the  femur,  and  the  absence 
of  osseous  excrescence. 

23.  Old  luxations  may  possibly  require  the  aid  of  pulleys, 
in  order  by  traction  to  ayoid  any  danger  which  might  result 
to  the  atrophied  or  degenerated  neck  of  the  bone  from 
rotation. 

24.  Right-angled  extension,  the  femur  being  flexed  at  a  right 
angle  with  the  pelvis,  is  more  advantageous  than  that  which  has 
usually  been  employed. 

25.  To  make  such  extension  most  effective,  a  special 
apparatus  is  required. 


FRACTURES   OF   THE   NECK    OF   THE   THIGH-BONE. 

1.  The  terms  "intra"  and  "extra"  ca.psular,  applied  to  these 
fractures,  have  little  practical  significance,  because  when  a 
fracture  near  the  head  of  the  femur  shows  bony  union,  it  is 
often  impossible  to  say  whether  such  a  fracture  was  originally 
inside  or  outside  the  capsular  ligament. 

2.  These  fractures  are  therefore  better  divided,  for  practical 
purposes,  into  (1)  the  impacted  fracture  of  the  neck  into  the 
trochanter ;  and  (2)  other  fractures  of  the  neck. 


INTRODUCTION.  7 

3.  In  this  impacted  fracture,  the  litnh  is  everted  because  the 
posterior  cervical  wall  is  almost  always  impacted,  the  anterior 
very  rarely,  and  in  a  less  degree. 

4.  These  conditions  mainly  result  from  the  relative  thickness 
of  the  two  walls. 

5.  While  eversion  is  due  to  the  rotation  of  the  fractured  hone 
on  a  hinge  formed  in  the  anterior  cervical  wall,  shortening  is 
generally  due  to  the  obliquity  of  this  hinge. 

6.  In  a  well-formed  bone,  the  posterior  and  thin  surface  of 
the  neck  of  the  femur  is  prolonged  into  the  cancellous  structure 
beneath  the  intertrochanteric  ridge,  and  is  the  true  neck. 

7.  The  posterior  intertrochanteric  ridge  is  a  buttress  built 
upon  the  true  neck,  by  which,  when  impacted,  this  ridge  is 
sometimes  split  off. 


DISLOCATION    OF    THE    HIP. 


The  original  object  of  the  following  paper  was  to  show  that 
in  dislocations  of  the  hip  the  position  of  the  limb  depends 
chiefly  upon  a  ligament  which  has  been  of  late  years  imper- 
fectly described,  and  that  the  reduction  of  these  dislocations 
should  be  managed  accordingly.  In  connection  with  this 
subject,  I  also  attempted  to  show  how  the  anatomical  struc- 
ture of  the  neck  of  the  femur  leads  to  a  common  variety  of 
fracture  of  that  bone. 

These  views  have  been,  as  I  believe,  so  well  established  by 
repeated  experiments  upon  the  dead  subject,  and  so  corrobo- 
rated by  current  pathological  phenomena,  and  by  the  mass  of 
reported  cases  and  autopsies,  that  little  doubt  can  exist  of 
their  correctness. 

Since  about  the  year  1854-55,  the  four  dislocations  of  the 
hip,  as  usually  described,  together  with  the  method  of  redu- 
cing them  by  manipulation  alone,  have  been  annually  shown 
to  the  classes  attending  the  lectures  at  the  Medical  School 
of  Harvard  University.  These  four  luxations  were  made  in 
each  case  upon  a  single  dead  subject,  which,  notwithstanding 
the  great  laceration  to  which  the  capsule  of  the  hip  had  been 
subjected,  in  no  instance  failed  to  exhibit,  and  to  demonstrate 
in  a  striking  manner,  the  appropriate  and  well-known  attitude 
of  each  dislocation.  In  fact,  the  firm  and  persistent  posi- 
tion of  a  joint  displaced  under  such  circumstances  is  quite 
remarkable.     In  these  experiments,  the  fixed  attitude  of  the 


10  DISLOCATION    OF    THE   HIP. 

limb  was  at  first  attributed  to  the  muscles,  which  when  fully- 
extended  are  capable  of  considerable  resistance  in  the  dead 
subject  as  well  as  in  the  living  one ;  but  it  was  supposed  that 
the  action  of  their  complicated  mechanism  would  hardly  repay 
the  labor  of  its  study. 

In  the  spring  of  1861,  having  been  led  to  expose  a  joint, 
the  luxation  of  which  had  been  the  subject  of  a  lecture,  I 
was  agreeably  surprised  to  observe  the  simple  action  of  the 
ligament,  —  a  simplicity  which  subsequent  experience  has 
confirmed,  and  which  strikingly  explains  the  phenomena 
observed  in  the  living  subject.^ 

The  dislocated  joint  alluded  to  presented  on  examination 
the  following  appearances  :  — 

1.  Great  laceration  of  the  muscles  about  the  joint. 

2.  The  ligamentum  teres  broken. 

3.  Laceration  of  the  inner,  outer,  and  lower  parts  of  the 
capsule. 

4.  The  anterior  and  upper  parts  of  the  capsule  uninjured, 
and  presenting  a  strong  fibrous  band,  fan-shaped,  and  slightly 
forked. 

The  remaining  tendinous  and  muscular  fibres  about  the 
joint  being  now  completely  divided,  with  the  exception  of 
the  strong  fibrous  band  above  alluded  to,  it  was  found  that 
the  four  commonly  described  dislocations  of  the  hip  could 
still  be  exhibited  without  difficulty,  and  that  in  each  of  them 
the  anterior  portion  of  the  capsular  ligament,  which  alone 

1  Of  the  figures  accompanying  this  paper,  those  of  the  Y  ligament  num- 
bered 1,  0,  7,  8, 19,  24,  25,  27,  29,  31,  and  of  the  impacted  fracture,  1,  2,  3, 
were  reproduced,  in  the  spring  of  1861,  from  photographs  made  from 
this  hip  after  dissection.  In  June,  1861,  a  paper  upon  the  subject  was 
read  before  the  Boston  Society  for  Medical  Improvement;  a  second  paper 
before  the  Massachusetts  Medical  Society,  in  May,  1864;  another,  in  June, 
1865,  before  the  American  Medical  Association.  In  the  present  paper  the 
rarer  forms  of  dislocation  have  been  added,  with  references  to  the  more 
interesting  reported  cases. 


DISLOCATION    OF   THE    HIP.  11 

remained,  sufficed  at  once  to  direct  the  limb  to  its  appropriate 
position  and  to  fix  it  there. 

Assuming  that  each  of  these  dislocations  does  occur,  and 
that,  however  much  it  may  vary  in  degree,  it  uniformly 
exhibits  its  proper  and  familiar  diagnostic  signs ;  that  the 
anterior  portion  of  the  ligament  of  the  capsule  far  exceeds 
in  strength  any  other  part  of  it,  and  that  on  this  account 
it  not  only  is  less  likely  to  be  torn,  but  generally  remains 
intact ;  that  when  this  alone  remains,  it  is  itself  able  to 
give  position  to  the  displaced  limb ;  and  that  when  it  is 
divided,  the  other  parts  of  the  capsule,  the  muscles,  and 
other  tissues  do  this  very  imperfectly,  as  will  be  hereafter 
shown,  —  then  the  a  'priori  evidence  is  strong  that  a  luxated 
femur  assumes  its  attitude  chiefly  in  obedience  to  the  trac- 
tion of  the  tense  fibres  of  this  part  of  the  ligament. 

The  resistance  of  a  dislocated  limb  is  unyielding,  and  unlike 
that  of  muscular  action  elsewhere,  —  in  illustration  of  which 
a  few  cases  may  be  cited,  taken  almost  at  random  from  Sir 
Astley  Cooper.^ 

"  Case  XXXVIII. —  .  .  .  He  was  bled  thirty  ounces  in  the 
recumbent  posture,  and  small  doses  of  tartarized  antimony  were 
administered,  but  without  these  means  producing  syncope.  He 
was  then  placed  upon  a  large  table,  and  his  pelvis  fixed  in  the 
usual  manner,  by  long  jack-towels  passed  between  the  perinaeum 
and  the  injured  joint;  the  extending  apparatus,  composed  also  of 
a  round  towel,  was  then  applied  above  the  knee,  and  to  it  were 
attached  weights  to  the  amount  of  one  hundred  and  twelve  pounds, 
fastened  to  a  rope,  which  was  rove  through  a  pulley.  To  the  influ- 
ence of  this  weight  he  was  submitted  for  four  hours,  but  without 
any  effect  being  produced.  He  was  therefore  then  sent  to  Guy's 
Hospital.  At  half-past  seven  p.  m.  he  was  taken  into  the  operat- 
ing theatre.  The  pelvis  was  fixed  by  the  common  padded  bandage, 
while    to    the   knee   was    attached  the   circular  bandage    and  pul- 

1  A  Treatise  on  Dislocations  and  Fractures  of  the  Joints,  London, 
1842. 


12  DISLOCATION  OF  THE   HIP. 

leys,  and  gradual  extension  was  made  across  the  lower  third  of 
the  opposite  thigh  for  the  space  of  twenty  minutes,  during 
which  period  he  was  given  three  grains  of  tartarized  antimony 
in  solution." 

''Case  L.  —  John  Cockburn,  a  strong,  muscular  man,  aged 
thirty-three,  was  admitted  into  Guy's  Hospital  on  the  31st  of 
July,  1819.  While  carrying  a  hag  of  sand  at  Hastings  on  the 
24th  of  July,  he  slipped,  and  dislocated  the  left  hip-joint.  The 
foot  on  the  affected  side  was  plunged  suddenly  into  a  hollow  in 
the  road,  which  turned  his  knee  inward  at  the  same  time  that 
his  body  fell  with  violence  forward.  On  the  day  of  the  accident 
two  attempts  were  made  to  reduce  the  dislocation  by  pulleys,  but 
without  success;  and  on  the  27th  of  July  a  third,  but  equally 
unsuccessful,  trial  was  made,  although  continued  for  nearly  an 
hour. 

''It  was  found,  upon  examination,  that  the  thigh  was  dislocated 
backward  into  the  ischiatic  notch.  The  patient  was  carried  into 
the  operating  theatre  soon  after  his  admission;  and  when  two 
pounds  of  blood  had  been  taken  from  him,  and  he  had  been  nause- 
ated by  two  grains  of  tartarized  antimony,  gradually  administered, 
extension  was  made  with  the  pulleys  in  a  right  line  with  the  body, 
and  the  upper  part  of  the  thigh  was  raised,  while  the  knee  was 
depressed.  The  extension  was  continued  at  least  for  an  hour  and 
a  half,  during  which  time  he  took  two  grains  more  of  tartarized 
antimony,  by  which  he  was  thoroughly  nauseated.  The  attempts 
at  reduction,  however,  did  not  succeed."  ^ 

To  a  surgeon  accustomed  to  the  comparative  ease  with 
which  the  powerful  muscles  of  a  recently  fractured  thigh 
may  be  extended  by  a  moderate  effort  continuously  applied, 
these  cases  of  enormous  resistance  in  the  reduction  of  a  dis- 
located hip  suggest  a  force  more  powerful  and  unyielding 


1  It  is  curious  to  remark  that  this  case  ultimately  yielded,  in  the  hands 
of  Sir  Astley,  to  the  employment,  unusual  for  him,  of  the  flexion  method, 
though  combined  with  pulleys.  In  further  illustration  of  the  disadvan- 
tage of  horizontal  extension,  let  this  case  be  compared  with  a  similar  one 
(dorsal  below  the  tendon)  where  the  reduction  occupied  three  seconds 
(p.  69). 


DISLOCATION   OF  THE    HIP.  13 

than  that  of  muscular  action.  Indeed,  the  facility  with  which 
muscular  contraction  is  overcome  by  ether,  while  the  deform- 
ity and  resistance  of  dislocation  continue,  should  long  ago 
have  led  to  the  conviction  that  muscular  contraction  is  not 
a  chief  agent  in  this  deformity. 

But  modern  writers,  with  few  exceptions,  have  adopted  the 
theory  of  active  or  passive  muscular  resistance.  Sir  Astley 
Cooper  says :  — 

' '  With  respect  to  the  fixed  position  of  the  head  of  the  femur  in 
the  four  dislocations  which  have  heen  described,  it  is  not  to  be  con- 
sidered as  a  mere  matter  of  chance,  but  the  natural  result  of  the 
influence  of  the  muscles,  which  draw  the  bone  into  these  positions; 
and  that  therefore,  under  common  circumstances,  the  condition  is 
inevitable.^  .  .  .  The  capsular  ligaments,  in  truth,  possess  but  little 
strength  either  to  prevent  dislocation  or  to  resist  the  means  of  re- 
duction. .  .  .  The  difficulty  of  reducing  dislocations  arises  neither 
from  the  bones  nor  from  the  ligaments,  but  from  the  resistance 
which  the  muscles  present  by  their  contraction."  ^ 

Dr.  Nathan  R.  Smith  recognizes  muscular  contraction  as 
the  chief  agent  in  effecting  both  dislocation  of  the  hip  and 
its  reduction.^ 

That  similar  views  are  still  entertained  by  distinguished 
surgical  authorities  is  shown  by  the  following  reported  re- 
marks of  M.  Chassaignac  at  a  meeting  of  the  Societe  de 
Chirurgie  in  1865 :  "  The  employment  of  chloroform  in  the 
reduction  of  dislocations  had  convinced  him  [M.  Chassaignac] 
that  obstacles  to  reduction  said  to  be  due  to  other  causes  than 
muscular  contraction  were  chimerical,"  *  —  an  observation  that 
seems  to  have  passed  unchallenged. 

1  A  Treatise  on  Dislocations  and  Fractures  of  the  Joints  (p.  100). 
London,  1842. 

2  Ibid.,  pp.  20,  21. 

3  Medical  and  Surgical  Memoirs  (pp.  166,  167).  By  Nathan  Smith, 
M.  D.     Edited  by  Nathan  R.  Smith,  M.D.     Baltimore,  1831. 

*  London  Medical  Times  and  Gazette,  December,  1865  (p.  661). 


14  DISLOCATION  OF  THE  HIP. 

Dr.  Reid  makes  tlie  following  statement :  — 

"The  chief  impediment  in  the  reduction  of  dislocation  is  the 
indirect  action  of  muscles  that  are  put  upon  the  stretch  by  the 
malposition  of  the  dislocated  bone.  .  .  .  The  limb  or  bone  should 
be  drawn  in  the  direction  which  will  relax  the  distended  muscles."  ^ 

On  the  other  hand,  the  theory  of  ligamentous  resistance  has 
been  occasionally  and  distinctly  recognized. 

Boyer  expresses  his  conviction  of  the  importance  of  the 
ligament  in  this  relation,  but  without  proof.^ 

Professor  Gunn  maintains,  in  a  paper  ^  upon  this  subject, 
that  different  untorn  or  "•  undissected"  portions  of  the  cap- 
sular ligament  are  capable  of  producing  the  signs  of  hip 
and  shoulder  luxation ;  while,  since  the  reading  of  the  pres- 
ent paper,  Professor  W,  Busch,*  at  the  Bonn  Clinic,  has 
recognized  the  resistance  to  the  reduction  of  dislocation  as 
ligamentous  and  capsular,  although  he  fails  to  identify  the 
anterior  ligament  as  its  principal  seat. 

There  is  no  doubt  that  in  luxation  as  well  as  in  fracture 
the  muscles  soon  contract  and  adapt  themselves  to  the  new 
condition  of  things ;  so  that  the  limb  is  steadied  partly  by 
the  effort  of  the  patient.  In  those  luxations  of  the  hip, 
for  example,  which  exhibit  great  flexion,  the  muscles  while 
active  may  contribute,  when  the  patient  is  standing,  to  sup- 
port the  limb  in  a  flexed  position,  while  its  own  weight  tends 

1  Dislocation  of  the  Femur  on  the  Dorsum  Ilii  reducible  without 
Pulleys  or  any  other  Mechanical  Power,  (p.  41).  By  William  W.  Reid, 
M.  D.,  of  Rochester.  Transactions  of  the  N.  Y.  Medical  Society.  Albany, 
1852. 

2  Traite  des  Maladies  Chirurgicales,  etc.  (tom.  iv,  p.  282).  Par  M. 
le  Baron  Boyer.     Paris,  1822. 

*  Luxations  of  the  Hip  and  Shoulder,  and  the  Agents  which  oppose 
their  Reduction.  By  Moses  Gunn,  A.  M.,  M.  D.,  Professor  of  Surgery  in 
the  University  of  INlichigan.     Detroit,  1859. 

*  Year-Book  of  Medicine,  Surgery,  etc.,  for  1863  (p.  22.5.)  Sydenham 
Society.     London,  1864. 


DISLOCATION   OF   THE   HIP.  15 

to  straighten  it ;  they  may  even  help  to  convert  a  dislocation 
below  the  socket  into  one  upon  the  dorsum,  or  into  the  fora- 
men ovale,  —  or  they  may  assist  simply  to  reduce  it.  But 
there  is  no  evidence  that  dislocations  below  the  socket  are 
capable  of  retaining  their  distinctive  features  in  an  erect 
posture  of  the  body,  when  the  muscles  are  relaxed,  as  in  the 
dead  or  etherized  subject. 

Again,  some  of  the  muscles  are  stretched  and  elongated  by 
the  luxated  bone ;  and  their  passive  strength  under  these  cir- 
cumstances, which  is  greater  than  might  be  supposed,  has 
been  well  illustrated  by  Dr.  Reid.  But  it  is  unnecessary  to 
dwell  upon  the  tenacity  of  the  muscular  fibre  passively 
stretched  to  its  extreme  limit,  because  this  extreme  tension 
does  not  occur  in  the  usual  dislocations,  being  prevented  by 
the  ligamentous  action.  It  may  be  remarked,  however,  that 
muscle  is  far  less  strong  than  ligament ;  and  that  the  muscles 
about  the  hip,  which  are  inserted  near  the  head  of  the  femur, 
are  acted  upon  at  great  advantage  by  this  powerful  lever,  and 
might  yield  were  they  unsupported.  Moreover,  the  dislocated 
hip  can  be  shown  equally  well  upon  a  subject  in  which  the 
muscles  have  become  soft  by  decomposition  ;  and  when  the 
four  classical  dislocations  have  been  produced  upon  a  single 
subject,  most  of  the  muscular  tissue  immediately  surrounding 
the  joint  will  be  found  to  have  been  torn  away,  while  the  rest 
may  be  divided  without  materially  affecting  the  power  of  the 
limb  to  illustrate  these  four  luxations.  On  the  other  hand,  — 
a  fact  which  is  conclusive,  —  if  the  entire  capsule  of  the  hip 
joint  be  divided  and  the  muscles  left  intact,  these  dislocations 
are  but  imperfectly  represented. 

Without  denying,  then,  that  muscular  fibre  exerts  both  an 
active  and  a  passive  force,  it  is  here  assumed  that  the  muscles 
play  but  a  subordinate  and  occasional  part  either  in  hindering 
reduction  or  in  determining  the  character  of  the  deformity, 
and  that  this  is  chiefly  due  to  the  resistance  of  a  ligament 


16  DISLOCATION  OF  THE   HIP. 

the  power  of  which  will  presently  be  illustrated,  and  whose 
simple  mechanism  will  explain  the  phenomena  both  of  luxa- 
tion and  its  reduction.  Out  of  twenty-two  recorded  autopsies, 
while  in  two  only  is  there  any  allusion  to  the  rupture  of  the 
anterior  portion  of  the  capsule,  in  fourteen  it  is  distinctly 
mentioned  that  it  remained  wholly  or  in  part  unbroken, — 
a  large  proportion,  considering  that  attention  has  hitherto 
not  been  directed  to  this  point.  It  is  not  here  maintained 
that  this  ligament  will  be  found  stripped  clear  of  the  re- 
maining portion  of  the  capsule,  —  the  comparatively  few 
autopsies  on  record  showing  that  this  is  not  the  case;  there 
is,  however,  reason  to  believe  that  the  thinner  portions  owe 
their  immunity  from  injury  to  the  protection  of  the  main 
ligament. 

The  theory  here  advanced  recognizes  the  anterior  portion 
of  the  capsular  ligament  as  the  exponent  of  the  total  agency 
of  the  capsule  in  giving  position  to  the  dislocated  limb,  and, 
what  is  more  important,  as  so  identified  with  the  phenomena 
of  luxation  that  reduction  must  be  accomplished  almost 
wholly  with  reference  to  it.  It  remains  for  future  autopsies 
to  show,  by  careful  examination,  how  far  the  usual  phenomena 
either  of  luxation  or  its  reduction  can  occur  after  rupture  of 
this  ligament. 

THE   Y  LIGAMENT. 

The  ilio-femoral  ligament,  known  also  as  the  ligament  of 
Bertin,  has  been  usually  described  as  reinforcing  the  capsule  by 
a  single  fibrous  band  extending  from  the  inferior  iliac  spine 
to  the  inner  extremity  of  the  anterior  intertrochanteric  line, 
and  playing  no  very  important  part  in  health  or  injury.  This 
ligament  is  more  or  less  adherent  to  the  acetabular  promi- 
nence and  to  the  neck  of  the  femur ;  but  upon  examination 
it  will  be  found  to  take  its  origin  from  the  anterior  inferior 
spinous  process  of  the  ilium,  passing  downward  to  the  front 


DISLOCATION   OF  THE   HIP. 


17 


of  the  femur,  to  be  inserted  fan-shaped  into  nearly  the  whole 
of  the  oblique  spiral  line  which  connects  the  two  trochan- 
ters in  front,  —  being  about  half  an  inch  wide  at  its  upper 
or  iliac  origin,  and  but  little  less  than  two  inches  and  a  half 
wide  at  its  fan-like  femoral  insertion.  Here  it  is  bifurcated, 
having  two  principal  fasci- 
culi, one  being  inserted  into 
the  upper  extremity  of  the 
anterior  intertrochanteric 
line,  and  the  other  into  the 
lower  part  of  the  same  line, 
about  half  an  inch  in  front 
of  the  small  trochanter. 
The  ligament  thus  resembles 
an  inverted  Y,  which  sug- 
gests a  short  and  convenient 
name  for  it. 

The  divergent  branches  of 
the  Y  ligament  are  some- 
times well  developed,  with 
scarcely  any  intervening 
membrane.  In  other  cases 
the  intermediate  tissue  is 
thicker,  and  requires  to  be 
slit  or  removed  before  the 
bands  are  distinctly  defined, 

and  sometimes  the  whole  triangle  is  of  nearly  uniform  thick- 
ness. In  the  subject  first  dissected,  and  from  which  the 
accompanying  woodcut  was  designed,  the  external  fasciculus 
of  fibres  was  nearly  as  well  developed  as  the  inner  band ;  in 
two  other  subjects  it  was  actually  wider  and  thicker.     But  as 

1  The  Y  ligament,  showing  its  inner  and  outer  fasciculi.  The  former 
is  known  as  the  ilio-femoral  ligament,  the  ligament  of  Bertin,  etc.  This 
specimen  shows  the  interval  between  the  two  fasciculi. 

2 


Fig.  1.1 


18  DISLOCATION  OF  THE  HIP. 

the  internal  and  external  branches  exercise  somewhat  distinct 
functions,  —  the  one  being  chiefly  concerned  in  limiting  the 
extension,  the  other  the  eversion,  of  the  femur,  and  also  in 
producing  inward  rotation  in  dorsal  dislocation,  —  it  is  fair  to 
infer  that  in  a  normal  condition  they  would  exhibit  greater 
development  than  the  intermediate  fibres. 

The  Y  ligament  is  of  remarkable  tenacity  and  strength, 
being  at  some  points,  when  well  developed,  nearly  a  quarter 
of  an  inch  in  thickness,  and  forming  an  unyielding  suspensory 
band,  by  which  the  femur,  when  in  a  state  of  extension,  as  in 
walking,  is  forcibly  retained  in  its  socket. 

In  six  by  no  means  recent  subjects,  taken  at  random  from 
the  dissecting-tables  and  suspended  by  the  shoulders,  the 
lower  limbs  being  united  to  the  pelvis  by  the  Y  ligament 
alone,  this  ligament  required  for  its  rupture  the  attach- 
ment of  weights  to  the  foot,  varying  in  the  several  cases 
from  two  hundred  and  fifty  to  seven  hundred  and  fifty 
pounds  .1 

The  dissection  of  the  Y  ligament  here  represented,  taken 
from  a  photograph  made  in  1861,  first  directed  my  attention 
to  the  anatomical  arrangement  and  strength  of  its  fibres. 
Some  seven  years  after  this  Y  was  photographed,  I  found 
upon  referring  to  works  in  the  library  of  my  distinguished 
colleague.  Professor  0.  W.  Holmes,  the  following  passages, 
which  show  that  a  bifurcation  of  this  ligament  was  known 
to  some  of  the  earlier  anatomists,  although  it  has  since  been 
generally  overlooked. 

The  first  is  from  Winslow :  — 

1  Although  autopsies  show  that  the  whole  of  this  ligament  has  some- 
times been  torn  asunder,  it  may  be  assumed  that  such  a  lesion  is  likely 
to  be  of  rare  occurrence.  Its  strength  probably  insures  its  immunity  in 
a  large  majority  of  luxations  ;  while  the  constancy  of  their  signs,  which 
will  be  shown  to  be  best  explained  by  the  action  of  this  ligament,  testi- 
fies to  its  integrity. 


DISLOCATION  OF  THE   HIP.  19 

''It  [the  ligament]  is  very  thick  between  the  anterior  inferior 
spine  of  the  os  ilium  all  the  way  to  the  small  anterior  tuberosity 
which  unites,  as  it  were,  the  basis  of  the  great  trochanter  with  the 
basis  of  the  neck.  It  is  likewise  very  thick  between  the  same  spine 
and  the  middle  part  of  the  oblique  rough  line  observable  between 
the  tuberosity  and  the  little  trochanter;  and  here  likewise  it  is 
strengthened  by  a  bundle  of  fibres  connected  to  the  passage  of  the 
tendon  of  the  iliac  muscle  and  to  the  inferior  portion  of  the 
oblique  rough  line.  The  disposition  of  the  ligamentous  fibres 
of  which  these  two  thick  portions  are  composed  forms  a  sort  of 
triangle  with  the  oblique  rough  line  which  terminates  the  basis 
of  the  neck."i 

Weitbrecht,  an  excellent,  perhaps  the  best,  authority  up- 
on the  ligaments,  referring  in  this  connection  to  Winslow, 
distinctly  recognizes  a  forked  arrangement,  which  he  thus 
describes :  — 

"  Partim  anterius  versus  collum  femoris  et  trochanterem  mino- 
rem  procedit,  .  .  .  partim  vero  lateraliter  versus  exteriora  progre- 
ditur,  et  circa  radicem  trochanteris  majoris  in  tuberculo  laterali 
terminatur.  Atque  binae  hae  divaricationes,  una  cum  linea  obli- 
qua,  figuram  .    .    .   triangularem  .   .   .   constituunt."  ^ 

The  Webers  describe  the  ligament  as  triangular,  laying 
stress  upon  its  thickness,  which,  as  they  assert,  is  greater 
than  that  of  the  ligament  of  the  patella  or  the  tendo  Achillis, 
and  concluding  thus  :  — 

"With  this  great  strength  we  should  expect  that  every  other 
part  of  the  capsule  would  be  ruptured  before  this  ligament;  and 
that  even  the  bone  itself  would  first  yield.  "^ 

^  An  Anatomical  Exposition  of  the  Structure  of  the  Human  Body 
(sect.  2,  pp.  138-139).  By  James  Benignus  Winslow.  (Douglas's  Trans- 
lation.)    London,  1776. 

2  Syndesmologia,  sive  Historia  Ligamentorum,  etc.  (p.  141).  Josias 
Weitbrecht,  D.  M.     Petropoli,  1742. 

3  Traite  d'Osteologie,  etc.  (pp.  323,  324).  S.  P.  Soemmerring,  and 
G.  and  E.  Weber.     Paris,  1843. 


20  DISLOCATION  OF  THE  HIP. 

CAPSULE   OF   THE   HIP. 

In  a  front  view  of  the  cleanly  dissected  capsule  of  the  joint, 
the  Y  ligament  is  distinctly  seen,  the  tissue  occupying  its  fork 
being  sometimes  a  mere  membrane,  and  sometimes  thicker. 
The  external  band  hinders  eversion,  especially  when  the  leg 
is  extended.  Both  bands  limit  extension.  In  abducting  the 
leg,  a  band  is  raised  (pubo-femoral)  between  the  bony  ridge 
above  the  thyroid  foramen  and  the  prominence  at  the  inner 
part  of  the  intertrochanteric  line,  hindering  abduction  in  every 
position  of  the  limb.  Between  this  band  and  the  Y  ligament 
the  capsule  is  comparatively  thin  ;  and  here  the  primitive  pu- 
bic dislocation  doubtless  occurs.  Behind  and  inside  the  pubo- 
femoral band,  looking  directly  toward  the  thyroid  foramen, 
is  found  the  thinnest  part  of  the  capsule,  which  at  this  point 
resembles  wet  bladder,  readily  permitting  the  thyroid  dislo- 
cation. Outside  and  behind  the  Y  ligament,  where  the  dorsal 
dislocations  occur,  the  capsule  is  very  strong,  limiting  adduc- 
tion and  rotation  inward.  There  is  also  a  fasciculus  from  the 
tuber  ischii  at  its  upper  part  to  the  upper  part  of  the  trochanter 
behind,  arresting  flexion  and  inversion.  The  principal  liga- 
mentous bands  are  the  two  first  described,  —  no  part  of  the 
capsule  comparing  in  strength  with  the  Y  ligament  and  the 
tissue  which  lies  immediately  behind  it,  beneath  the  tendon 
of  the  obturator  internus  muscle. 

LIGAMENTUM   TERES. 

Little  can  be  added  to  the  excellent  paper  of  Mr.  Struthers  ^ 
upon  the  function  of  this  ligament.  When  the  limb  is  bent 
upon  the  body,  it  hinders  eversion,  —  thus  opposing  the  action 
of  the  sartorius  muscle,  and  hindering,  in  this  position,  dis- 
location upon  the  thyroid  foramen.  It  is  not,  however,  pos- 
sessed of  much  strength ;  is  ruptured  in  all  the  complete  and 

1  Edinburgh  Medical  Journal,  November,  1858  (p.  434). 


DISLOCATION  OF  THE  HIP.  21 

sudden  dislocations,  and,  according  to  Cruveilhier,  is  often 
undeveloped  and  sometimes  wanting. 

OBTURATOR   INTERNUS   MUSCLE. 

It  will  hereafter  be  seen  that  this  muscle,  with  which  the 
gemelli  are  practically  identified,  is  materially  concerned  in 
one  variety  of  hip  dislocation,  and  is  important  in  relation  to 
its  reduction.  There  is  a  peculiarity  of  the  obturator  internus, 
hitherto  undescribed,  which  explains  its  strength.  Its  mus- 
cular belly  is,  in  some  subjects,  mingled  with  tendinous  fibres. 
This  may  be  verified  in  dissection  by  reflecting  the  muscle  from 
its  pulley  so  as  to  expose  its  internal  and  fibrous  surface.  The 
four  or  five  tendinous  divisions  which  wind  round  the  lesser 
sacro-sciatic  notch,  and  which  seem  to  disappear  in  the  thick- 
ness of  the  muscular  tissue,  may  then  be  traced  in  part  to  a 
bony  origin,  some  of  their  minute  and  ultimate  fibres  arising 
from  the  margin  of  the  obturator  foramen.  The  muscle,  when 
extended,  thus  practically  becomes  a  ligament,  and  by  the 
attachment  of  its  combined  tissues  acquires  great  strength. 
Again,  the  friction  of  the  tendon  over  the  pulley  lessens  the 
draft  upon  the  extended  muscle,  and  so  increases  its  power 
of  resistance  that  it  is  the  strongest,  as  in  relation  to  luxa- 
tion it  is  the  most  important,  of  the  small  outward  rotators 
of  the  hip.i  That  portion  of  the  capsule  which  lies  directly 
beneath  the  tendon  is  also  very  strong ;  and  while  their  fibres 
mutually  reinforce  one  another,  their  mechanical  action  in 
the  dorsal  luxations  is  much  the  same. 

1  The  average  weight  required  to  rupture  this  and  the  adjacent  mus- 
cles in  four  subjects  is  as  follows  :  — 

Pyriformis  10  lbs.         Obturator  externus  36-|  lbs. 

Obturator  internus  40|  "  Gluteus  medius         17      " 

In  the  only  recent  subject  among  these,  the  obturator  internus  on  one 
side  parted  at  64  lbs.  and  on  the  other  at  60  lbs.,  the  obturator  externus 
at  52  and  44  lbs.,  and  the  pyriformis  at  16  lbs. 


22 


DISLOCATION  OF  THE  HIP. 


Arising  within  the  pelvis,  the  obturator  internus  emerges 
from  the  pelvic  cavity  at  a  point  several  inches  behind  the 
great  trochanter,  into  the  back  and  upper  part  of  vrhich  it  is 
inserted.  By  its  contraction  it  draws  the  trochanter  back- 
ward, everting  the 
thigh  when  straight, 
and  abducting  it  if 
flexed.  Upon  the 
dead  or  etherized 
subject  it  is  ren- 
dered tense  in  the 
extended  limb  by 
rotation  inward,  ad- 
duction being  then 
more  limited;  but  in 
the  flexed  limb,  and 
especially  in  extreme 
flexion,  it  is  relaxed ; 
so  that  in  reducing 


a  backward  disloca- 
tion, when  this  mus- 
cle is  still  entire,  it 
might  be  advanta- 
geous to  flex  the  limb 
as  much  as  possible. 
A  curious  corroboration  of  the  importance  of  this  muscle, 
as  well  as  of  the  external  branch  of  the  Y  ligament,  is  seen  in 
a  preparation  ^  of  my  own,  the  case  having  been  one  of  old 
ununited  fracture  of  the  neck  of  the  femur,  in  a  subject  the 
weight  of  whose  body  in  walking  had  been  suspended  chiefly 

1  Ununited  fracture  of  the  neck  of  the  thigh-bone,  showing  the  hyper- 
trophied  outer  fascicuhis  of  the  ligament  supporting  the  weight  of  the 
pelvis  in  walking.     The  inner  fasciculus  is  seen  below. 

2  No.  2715,  The  Warren  Anatomical  INIuseum  of  Harvard  University. 


Fig.  2.1 


DISLOCATION  OF  THE   HIP. 


23 


between  the  outer  branch  of  the  Y  ligament  in  front  and  the 
obturator  internus  behind  (Figs.  2  and  3).  This  is  probably 
the  usual  condition  of  patients  after  this  injury,  where  the 
shaft  of  the  femur  moves  freely  upon  the  detached  head  of 
the  bone. 


OTHER   MUSCLES. 

It  has  already 
been  stated  that 
the  restricted  move- 
ments of  the  thigh 
in  the  various  luxa- 
tions are  in  part  due 
to  the  active  and 
passive  resistance 
of  several  muscles 
which  (like  the  pso- 
as and  iliacus)  con- 
nect the  femur  with 
the  pelvis,  and  be- 
come more  or  less 
tense  by  its  displace- 
ment ;  yet  their  ac- 
tion, in  a  practical 
point  of  view,  is  of 
secondary  importance,  whether  considered  in  relation  to  its 
direction  or  its  extent.  Without  the  powerful  ligament  and 
the  muscle  already  described,  the  regular  femoral  luxations 
would  lose  much  of  their  present  distinctive  character;  and 
regard  being  had  to  the  action  of  these  fibrous  bands,  the  dis- 
locations can  be  reduced  with  little  reference  to  the  muscles. 

1  Fig.  2  seen  from  behind,  to  show  the  tense  obturator  tendon 
bearing  its  share  of  the  weight  of  the  body.  The  inferior  gemellus, 
hypertrophied,  is  seen  below  it.  ,, 


Fig.  3.1 


24  DISLOCATION  OF  THE   HIP. 

It  may,  however,  be  briefly  stated  that  the  gemelli  are 
practically  identified  with  the  obturator  internus,  while  the 
obturator  externus  below  it  and  the  pyriformis  above  it  are 
also  outward  rotators,  —  the  whole  forming  a  deep  muscular 
layer  with  interstices.  The  quadratus  femoris  muscle  is  below 
the  usual  range  of  dislocations,  but  is  easily  and  frequently 
torn ;  and  the  three  glutei  have  comparatively  little  efficacy 
in  rendering  the  femur  immovable,  even  when  its  head  is 
engaged,  for  example,  beneath  the  medius.  The  psoas  and 
iliacus  exert  a  force  in  the  direction  of  the  Y  ligament, 
especially  when  that  is  ruptured ;  and  if  the  limb  is  elon- 
gated, the  adductors,  the  flexors  of  the  leg,  the  tensor  vaginae 
femoris,  and  the  muscular  fibres  arising  from  the  anterior 
part  of  the  crest  of  the  ilium,  may  all  become  more  or 
less  tense.i 


DISLOCATIONS. 

Malgaigne  is  undoubtedly  right  in  assuming  that  disloca- 
tion of  the  hip  is  sometimes  only  partial.  These  various  de- 
grees of  dislocation  give  to  the  limb  the  slight  differences  of 
position  observed  in  different  cases  of  the  same  luxation.  But 
the  observation  is  not  new.  Hippocrates,  in  speaking  of  dis- 
location of  this  joint,  remarks :  "  In  a  word,  luxations  and 
sub-luxations  take  place  in  different  degrees,  being  sometimes 
greater  and  sometimes  less."  ^  Yet  it  cannot  be  denied  that 
the  general  character  of  the  deformity  is  the  same  for  the 
same  dislocation,  and  that  the  phenomena  were  on  the  whole 
well  described  by  Cooper,  and  by  preceding  writers  from  the 

1  In  a  case  of  persistent  flexion  after  reduction,  I  divided  these 
fibres.     (See  p.  55  of  this  volume.) 

2  The  Genuine  Works  of  Hippocrates,  etc.  (vol.  ii.  p.  631).  Printed  for 
the  Sydenham  Society.    London,  1849. 


DISLOCATION  OF  THE   HIP.  25 

time  of  Hippocrates,^  in  three  or  four  now  familiar  varieties, 
with  three  or  four  rarer  forms  of  displacement  considered  to 
be  anomalous. 

Accumulated  experience  has  justified  the  practical  value  of 
this  general  division,  which  should  not  be  lost  sight  of  either 
by  exaggerating  unimportant  differences,  or  through  needlessly 
obscuring  what  is  plain  by  names  of  recondite  derivation. 
Most  surgeons  have  seen  these  dislocations  in  the  living  sub- 
ject, and  although  the  rotation,  the  shortening,  or  other 
displacement  may  have  varied  a  little  in  each  case,  will  con- 
cede that  the  general  position  of  the  limb  is  too  constant  and 
characteristic  to  be  slighted  either  as  a  guide  to  the  direction 
of  the  luxation,  or  to  the  force  appropriate  for  its  reduction. 
I  have  therefore  adhered  as  far  as  possible  to  the  familiar 
names  of  hip  luxation,  which  as  usually  designated  are  those 
upon  the  dorsum,  the  ischiatic  notch,  the  thyroid  foramen,  and 
the  pubes.  Great  stress  having  been  laid  by  most  modern 
writers  on  a  distinction  between  the  first  two,  which  if  re- 
duced by  the  flexion  method  are  wholly  unimportant  varia- 
tions of  the  same  displacement,  I  shall  endeavor  to  show  how 
dorsal  dislocations  may  be  divided  for  practical  purposes  ; 
also,  that  certain  other  less  frequent  luxations,  hitherto  classed 
as  anomalous,  are  determined  by  the  same  mechanism  as  the 
rest,  and  with  equal  certainty. 

Assuming  that  the  Y  ligament  exerts  a  uniform  influence 
upon  the  several  dislocations,  they  will  be  here  described  with 
a  view  to  their  practical  arrangement,  according  to  the  follow- 
ing classification  :  — 

1  Hippocrates  describes  the  luxations  on  the  dorsum,  thyroid  foramen, 
and  pubes,  justly  including  with  the  first  variety  that  which  has  since 
been  called  "  dislocation  upon  the  ischiatic  notch,"  most  of  the  cases  so 
described  by  modern  writers  being  only  dorsal.  In  a  fourth  variety,  the 
dislocation  "  backward,"  —  which  has  been,  as  I  conceive,  eiToneously 
interpreted  by  his  translators  as  "  into  the  ischiatic  notch,"  —  Hippocra- 
tes describes  at  some  length  the  dislocation  du-ectly  downward. 


O 


26  DISLOCATION  OF  THE  HIP. 

I.  The  Regular  Dislocations,  in  which  one  or  both 
branches  of  the  Y  ligament  remain  unbroken. 

1.  Dorsal. 

2.  Dorsal   below    the   Tendon  (ischiatic   notcli   of 
Cooper). 

3.  Thyroid  and  Downward. 

Obliquely  inward  on  the  thyroid  foramen,  or  as 

far  as  the  perinseum. 
Vertically  downward. 
Obliquely  outward  as  far  as  the  tuberosity. 

4.  Pubic  and  Sub-spinous. 

5.  Anterior  Oblique. 

6.  SUPRA-SPINOUS.  )  ,    ,       , 

rr     -ny  T\  r  -Eixtemal  branch  broken. ^ 

7.  Everted  Dorsal.      ) 

II.  The  Irregular  Dislocations,  in  which  the  Y  ligament 
is  wholly  ruptured,  and  whose  characteristic  signs  are  therefore 
uncertain. 

general  remarks  upon  REDUCTION. 

When  the  patient  lies  upon  his  back,  especially  if  etherized, 
the  dislocated  limb  gravitates,  and  the  Y  ligament  becomes 
more  and  more  tense  as  the  limb  approaches  nearer  and  nearer 

1  Although  the  anterior-oblique,  supra-spinous,  and  everted  dorsal  luxa- 
tions resemble  one  another,  it  has  been  thought  advisable  to  distinguish 
between  them  for  the  purpose  of  more  accurately  classifying  recorded 
cases.  In  the  anterior  oblique  luxation  the  outer  branch  of  the  Y  liga- 
ment is  still  entire,  as  seen  in  the  figure  illustrating  this  luxation,  where 
the  ligament  is  of  uniform  thickness.  This,  indeed,  is  a  form  of  supra- 
spinous luxation ;  but  the  limb  cannot  be  brought  down  to  a  perpendicular, 
and  corresponds  in  position  with  that  in  a  case  reported  by  Cooper.  If 
the  limb  is  forcibly  brought  to  a  perpendicular,  the  external  branch  is 
ruptured ;  and  to  such  a  case  the  term  "  supra-spinous  "  is  here  assigned. 
The  term  "  everted  dorsal  "  is  intended  to  imply  a  power  of  eversion  more 
or  less  complete.  In  such  a  case  the  limb  may  be  everted  at  various 
angles,  which  can  happen  only  after  a  rupture  of  the  external  branch  of 
the  ligament. 


DISLOCATION  OF   THE   HIP.  27 

to  a  state  of  complete  extension.  If,  now,  as  is  here  main- 
tained, the  chief  obstacle  to  reduction  of  the  luxated  hip  is 
found  in  this  ligament,  it  follows  that  the  method  taught  by 
Sir  Astley  Cooper,  the  weight  of  whose  unquestioned  authority 
has  unfortunately  availed  to  give  it  currency  ^  during  many 
years,  is  based  upon  an  erroneous  conception  of  the  nature  of 
the  difficulty  to  be  encountered.  By  that  method  the  limb  is 
placed  as  nearly  as  may  be  in  the  axis  of  the  body,  —  thus 
rendering  the  Y  ligament  tense,  and  inviting  its  maximum  of 
resistance  before  traction  is  made.  Hence  the  necessity  for 
pulleys,  the  tendency  of  which  is  undoubtedly  to  elongate  or 
partly  detach,  at  its  femoral  insertion,  this  powerful  liga- 
mentous band,  at  great  sacrifice  of  mechanical  force,  with 
proportionate  violence  to  the  neighboring  tissues  and  uncer- 
tainty as  to  the  result.  By  the  flexion  method,  which  dates 
from  a  remote  antiquity,  the  Y  ligament  is  relaxed,  its  re- 
sistance annulled,  and  reduction  often  accomplished  with 
surprising  facility. 

The  following  is  the  statement  of  Hippocrates  on  this 
subject : — 

"  In  some  the  thigh  is  reduced  without  preparation,  with  slight 
extension,  directed  by  the  hand,  and  with  slight  movement;  and 
in  some  the  reduction  is  effected  by  bending  the  limb  at  the  joint, 
with  gentle  shaking."  ^ 

1  See  Edinburgh  Medical  Journal,  May,  1867,  —  "  On  the  Reduction  of 
Dislocations  of  the  Hip-joint  by  Manipulation."  By  Thomas  Annandale, 
Lecturer  on  Surgery,  etc.  "  Its  adoption  in  this  country  [reduction  by 
manipulation]  is  as  yet  by  no  means  general." 

2  Dr.  Adams,  in  his  Sydenham  Translation  of  Hippocrates,  renders  this 
passage,  "  bending  the  limb  at  the  joint,  and  making  rotation  "  (vol.  ii. 
p.  643).  Mr.  Sophocles,  the  distinguished  Professor  of  Greek  in  Harvard 
University,  has  kindly  furnished  me  the  following  conclusive  note,  defin- 
ing precisely  the  character  of  this  movement :  — 

"Your  question  has  reference  to  the  meaning  of  the  word  /cty/cXt- 
o-ty,  the  formation  of  which  is  as  follows :  KtyAcXoy,  wag-tail,  a  well-known 


28  DISLOCATION   OF   THE   HIP. 

In  view  of  this  observation  of  the  Coan  sage  (450  B.  c),  the 
indiscriminate  use  of  pulleys  hardly  testifies  to  the  progress  of 
modern  science. 

Flexion  lies  at  the  foundation  of  success  in  the  reduction  of 
femoral  dislocation  ;  and  compared  with  this  the  rest  of  the 
manipulation  is  of  secondary  importance.  It  may  be  taken 
a,s  a  safe  and  general  rule  that  after  the  thigh  has  been 
flexed  at  a  right  angle  the  head  of  the  bone  is  to  be  at 
once  guided  toward  the  socket,  and  that  if  the  capsular  ori- 
fice is  large  enough  the  operator  will  in  general  succeed ; 
while  it  is  equally  certain  that  in  the  extended  position  of 
the  limb  the  chances  are  all  against  him.  When  the  femur 
is  flexed,  reduction  may  be  effected  in  either  of  two  ways. 
In  the  first  (traction)  the  head  is  drawn  or  forced  at  once 
in  the  desired  direction ;  in  the  second  (rotatiori)  the  same 
result  is  accomplished  by  a  rotation  of  the  femur,  which,  in 
winding  ^  the  Y  ligament  about  its  neck,  shortens  it,  and  thus 
compels  the  head  of  the  bone,  as  it  sweeps  round  the  socket, 
also  to  be  guided  toward  the  socket.  In  reducing  a  hip,  the 
success  of  rotation,  adduction,  abduction,  and  extension  de- 
pends upon  this  ligament,  while  the  whole  manipulation  must 
be  conducted  with  reference  to  it. 

In  modern  times  the  flexion  method  has  commended  itself 
to  the  good  judgment  of  various  surgeons.  Many  cases  of 
successful  reduction  by  this  method  are  to  be  found  in  the 

bird  in  Greece,  called  also  areia-onvyis,  the  Latin  motacilla ,  KiyKki^ca,  to 
wag  (in  the  original  sense  of  the  term),  as  the  bird  aforesaid  wags  its 
tail. 

"  KiyKXiais  and  KiyKXia-ixos,  a  wag-tail  movement,  or  shaking  rapidly  within 
narrow  limits;  gentle  shaking.  The  words  circumaction  and  rotation  are 
out  of  the  question,  —  for  the  former  is  tts ptayw-yTj,  and  the  latter  kvkXo- 
(f)opia,  —  unless  rotation  be  used  in  a  peculiar  sense. 

"  Erotian,  in  his  Hippocratic  Glossary,  and  Galen,  define  KiyK\i<Tfx6s,  the 
synonym  of  Kiy«Xicrir,  by  ^paxe'ia  k'ivt]<tis,  short  motion,  like  that  of  the  tail 
of  the  bird  that  furnishes  the  word." 

1  See  Fig.  24. 


DISLOCATION  OF  THE   HIP.  2& 

journals,  and  many  more  have  been  unrecorded.  Among 
the  papers  explicitly  announcing  it  in  this  country  is  an 
original  one,  already  mentioned,  published  by  Dr.  Nathan 
R.  Smith  in  1831,  and  advocating  manipulation  against 
pulleys  in  dislocation  on  the  dorsum.  His  method,  which 
has  not  been  materially  improved,  consists  of  free  flexioiiy 
outward  rotation,  and  abduction,  the  employment  of  which 
he  ascribes  to  his  father,  the  late  distinguished  Prof.  Nathan 
Smith,  many  years  before.^  In  1852,  Dr.  W.  W.  Reid,  of 
Rochester,  N.  Y.,  published  a  paper  also  advocating  manipu- 
lation to  reduce  the  dorsal  luxation  (the  only  one  described), 
by  flexing  the  leg  on  the  thigh,  carrying  the  thigh  across  the 
sound  limb  upward  over  the  pelvis  as  high  as  the  umbilicus, 
and  then  abducting  it  and  carrying  the  foot  across  the 
opposite  sound  limb,^ — a  method  identical  in  its  important 
features  with  that  of  Nathan  Smith.^  But  these  and  other 
advocates  of  the  flexion  method  in  this  country  and  abroad 
were  anticipated  by  Hippocrates,  so  far  as  the  essential  prin- 
ciple of  flexion  is  concerned. 

It  is  desirable  that  before  handling  the  limb  the  surgeon 
should  accurately  conceive  not  only  the  general  object,  but 
the  details,  of  any  movement  he  intends  to  employ,  in  order 
that  the  joint  may  not  be  injured  by  random,  ill-devised,  and 
fruitless  manipulation.  A  slow,  steady,  well-directed  move- 
ment will  sometimes  accomplish  the  desired  result  in  a  few 
seconds,  while  an  ill-considered  or  uninstructed  effort  may 
be  continued  for  a  long  time  to  no  purpose. 

In  all  the  manoeuvres  the  gentle  shaking,  oscillation,  or 
rocking  motion  suggested  by  Hippocrates  may  be  useful  as 
the  head  approaches  the  socket. 

The  following  points  are  worthy  of  note. 

1  Medical  and  Surgical  Memoirs,  p.  177. 

2  Ibid.,  p.  35. 

8  See  also  note,  p.  65  of  this  voliune. 


30  DISLOCATION   OF  THE   HIP. 


POSITION   OF   THE   PATIENT   AND   SURGEON. 

The  patient  should  be  laid  upon  the  floor,  that  the  operator 
may  command  the  limb  to  the  best  advantage,  and  should  be 
etherized  until  the  muscles  of  the  hip  are  completely  relaxed.^ 

THE   Y    LIGAMENT,  WITH   REFERENCE   TO   REDUCTION   AND   TO 
SUBSEQUENT   TREATMENT. 

Except  in  the  supra-spinous  dislocations,  the  two  insertions 
of  the  Y  ligament  are  most  closely  approximated  when  the 

^  Some  wi'iters  have  expressed  a  different  opinion.  As  a  result  of  the 
theory  of  muscular  resistance,  Dr.  Reid  concludes  that  etherization  to  a 
state  of  complete  relaxation,  instead  of  being  an  advantage,  is  a  detri- 
ment, because  it  prevents  the  contraction  of  the  muscles  requu-ed  to 
replace  the  bone.  (See  a  paper  entitled  "  Observations  on  Dr.  Markoe's 
Report  of  Cases  of  Dislocation  of  the  Femur  treated  by  Manipulation.  By 
W.  W.  Reid,  M.  D.,  of  Rochester,  N.  Y."  New  York  Journal  of  Medicine, 
etc.,  July,  1855,  p.  72.)  Dr.  Reid  seems  here  to  add  the  theory  of  active 
muscular  resistance  to  that  of  passive  muscular  resistance,  already  quoted 
from  a  previous  paper  written  by  him. 

The  British  Medical  Journal  (Oct.  20,  1866)  contains  a  paper  read  by 
Mr.  Nunneley  at  a  recent  meeting  of  the  British  Medical  Association  at 
Chester,  "  On  the  Reduction  of  Dislocation  (more  especially  of  the  Hip 
and  Shoulder)  by  Manipulation,"  in  which  the  following  views  are  pre- 
sented :  "  The  most  important  condition  to  be  insured  is  a  relaxed  but 
not  perfectly  helpless,  flaccid,  uncontractile  condition  of  the  muscles,  as 
it  is  by  the  contraction  of  the  muscles  which  are  attached  near  to  the 
head  of  the  dislocated  bone  that  reduction  is  mainly  accomplished;  .  .  . 
while,  on  the  other  hand,  if  they  be  incapable  of  any  contraction  what- 
ever, it  will  frequently  be  found  to  be  impossible  for  any  manipulatory 
movements  of  the  surgeon  to  replace  the  bone,  or,  being  replaced,  for  its 
being  retained  in  that  position.  I  feel  confident  that  I  have  seen  both  of 
these  causes  materially  interfere  with  success,  particularly  the  latter  one, 
when  the  muscles  have  been  entirely  paralyzed  owing  to  the  anaesthesia 
having  been  too  profound." 

In  1844  a  patient  was  made  completely  insensible  by  the  administra- 
tion of  a  bottle  of  port  wine  and  half  a  bottle  of  rum  in  divided  doses, 
and  a  hip  reduction  was  accomplished  during  "  a  condition  of  muscular 
collapse."  London  Medical  Gazette,  1844,  p.  60 ;  from  Casper's  Wochen- 
schrift,  No.  9,  1844. 


DISLOCATION  OF  THE  HIP.  31 

thigh  is  flexed  upon  the  trunk,  carried  toward  the  navel,  and 
rotated  inward. 

But  it  has  happened  that  after  unsuccessful  efforts  a  hip 
has  been  reduced  when  semi-flexed  in  the  act  of  exten- 
sion ;  which  shows  that  in  certain  cases  the  ligament  may 
be  needlessly  relaxed  by  extreme  flexion,  and  may  be  ad- 
vantageously drawn  tighter  by  a  little  extension  or  outward 
rotation.^ 

I  may  here  refer,  in  connection  with  the  subsequent  treat- 
ment of  the  patient,  to  the  practical  importance  of  preventing 
such  a  relaxation  of  the  anterior  ligament,  whether  by  flexing 
the  thigh  or  raising  the  body  to  a  sitting  posture,  as  may  per- 
mit a  recurrence  of  luxation.  For  this  purpose,  where  the 
bone  inclines  to  slip  from  the  socket  after  reduction,  certain 
cases  may  require  not  only  that  the  limb  should  be  kept 
straight,  but  also  that  the  thigh  should  be  confined  for  a  time 
in  the  position  which  completed  the  reduction ;  namely,  for 
the  dorsal  luxations,  in  abduction  and  eversion,  or  in  vertical 
extension ;  for  the  pubic  and  thyroid,  in  a  position  of  inward 
rotation  and  adduction,  —  thus  taking  advantage  of  the  tense 
ligament  to  bind  the  bone  to  the  socket.^ 

1  Markoe,  in  an  interesting  paper  upon  this  subject,  states  that  he 
found  it  necessary  to  vary  a  little  from  the  method  by  flexion,  abduction, 
and  rotation  outwards,  recommended  by  Reid  in  dorsal  dislocation.  He 
says  :  "  It  failed  us  so  completely  from  the  first  that  we  were  led  to  add 
the  bringing  down  of  the  thigh  to  the  straight  position  in  a  state  of 
abduction,  still  keeping  up  the  rocking  motion ;  and  it  has  been  uni- 
formly in  the  act  of  thus  bringing  down  the  limb  that  the  reduction  has 
been  accomplished."  (See  "  An  Account  of  the  Cases  of  Dislocation  of 
the  Femur  at  the  Hip-Joint,  treated  by  Manipulation  alone,  after  the  Plan 
proposed  by  W.  W.  Reid,  M.  D.,  of  Rochester,  which  have  occurred  in 
the  New  York  Hospital  during  the  past  Two  Years.  By  Thomas  M. 
Markoe,  M.  D.,  one  of  the  Attending  Surgeons."  New  York  Journal  of 
Medicine,  etc.,  vol.  xiv.,  January,  1855,  p.  23.)  See  also  note,  p.  46  of  this 
volume. 

2  See  case,  p.  53  of  this  volume. 


32  DISLOCATION  OF  THE  HIP. 

HOW   THE   LIMB   IS   TO   BE   HELD. 

The  thigh  should  be  bent  upon  the  body,  and  the  leg  at  a 
right  angle  with  the  thigh.  With  one  hand  the  surgeon 
grasps  the  ankle  from  above,  while  with  the  other,  placed 
beneath  the  head  of  the  tibia,  he  lifts  and  guides  the  limb. 
In  this  way,  by  using  the  flexed  leg  as  a  lever,  keeping  it 
always  flexed  at  a  right  angle  for  that  purpose,  great  power  is 
brought  to  bear  upon  the  head  of  the  femur,  especially  in 
rotating  the  thigh.  It  is  therefore  important  to  keep  accurate 
account,  during  such  manipulation,  of  the  position  of  the  head 
of  this  bone,  which  should  not  be  moved  at  random,  or  indis- 
criminately urged  when  locked,  lest  it  be  broken  from  the 
shaft ;  and  it  may  be  convenient  to  remember  that  in  every 
position  the  head  of  the  femur  faces  nearly  in  the  direction 
of  the  inner  aspect  of  its  internal  condyle. 

CAPSULAR  ORIFICE  TO  BE  ENLARGED. 

Much  stress  has  been  laid  by  certain  writers  upon  the  diffi- 
culty of  replacing  the  head  of  the  bone,  when  it  has  escaped  by 
a  small  aperture  in  the  capsule.  That  this  condition  may  occa- 
sionally occur  seems  probable ;  and  it  is  suggested  by  Gelld,i  in 
his  elaborate  paper  upon  the  subject,  that  when  the  slit  occurs 
close  to  the  femoral  insertion  of  the  capsular  ligament,  it  may 
be  impossible  to  replace  the  head  of  the  bone.  This  writer, 
with  Malgaigne,  Gunn,  and  others,  urges  the  importance  of 
placing  the  bone  in  the  position  it  occupied  when  luxated, 
with  a  view  to  its  re-entering  the  socket  by  exactly  retracing 
its  path.  But  while  this  path  cannot  always  be  known,  any 
difficulty  is  easily  obviated  by  carrying  the  head  of  the  bone 
toward  the  opposite  side  of  the  socket,  and  thus  enlarging  the 

1  fitude  du  Role  de  la  Dechirure  Capsulaire,  etc.  Par  M.  Gelle.  Paris, 
1861. 


DISLOCATION  OF  THE   HIP.  33 

slit,  —  a  simple  manoeuvre,  easily  accomplished  by  circumduct- 
ing the  flexed  thigh  aci'oss  the  abdomen  in  a  direction  opposite 
to  that  in  which  it  is  desired  to  lead  the  head  of  the  bone,  which 
should  be  made  in  this  way  to  pass  across  below  the  socket, 
and  never,  it  is  needless  to  say,  above  it,  across  the  Y  liga- 
ment. This  expedient,  of  which  I  have  had  occasion  to  avail 
myself,  will,  as  I  believe,  be  in  future  generally  adopted  when 
any  such  difficulty  is  encountered  in  reducing  the  hip.  The 
subcutaneous  injury  is  trifling  in  comparison  with  that  result- 
ing from  a  protracted  and  ill-planned  manipulation,  or  from 
the  brute  force  of  pulleys.  Tt  depends  for  its  success  upon 
the  strength  of  the  Y  ligament,  which,  in  firmly  attaching  the 
base  of  the  neck  of  the  femur  to  the  inferior  spinous  process 
of  the  ilium,  forms  a  fulcrum  or  pivot  round  which  the  shaft 
and  the  neck  of  the  femur  can  be  made  to  revolve,  like  oppo- 
site spokes  in  a  wheel,  —  the  Y  ligament  being  strong  enough 
to  rupture,  in  this  way,  the  whole  of  the  rest  of  the  capsule 
and  the  obturator  muscle  without  itself  yielding.^ 

When  a  slit  has  thus  been  made  by  circumducting  the  neck 
of  the  bone  across  the  posterior  aspect  of  the  capsule,  the 
head  of  the  bone  has  traversed  an  interval  reaching  in  some 
cases  from  the  dorsum  to  the  thyroid  foramen,  and  slips 
readily  from  side  to  side.  This  laceration  already  exists  in 
most  cases  of  dorsal  dislocation  below  the  tendon,  where  the 
head  of  the  bone  has  reached  a  secondary  position  after  a  pre- 
vious luxation  downward,  and  is  also  known  to  surgeons  who 
have  reduced  dislocations  by  the  old  and  awkward  method  of 
extension,  where  the  bone  sometimes  slipped  many  times 
backward  and  forward  from  the  dorsum  to  the  foramen  ovale ; 
and  yet  I  can  find  recorded  only  one  instance  of  this  familiar 

1  Reid,  in  the  paper  already  quoted  (New  York  Journal  of  Medicine, 
July,  1885,  p.  69),  proposes,  in  a  similar  case,  "to  make  an  incision  down 
to  the  head  of  the  bone,  and  open  the  capsular  ligament  suflBcient  to 
admit  the  return  of  the  head  into  its  place."  .^ 

3 


34  DISLOCATION   OF   THE   HIP. 

occurrence  as  being  followed  by  any  permanent  injury,  and 
even  in  that  case  there  may  have  been  a  predisposition  to  the 
hip  disease  which  ensued.  It  will  hereafter  be  seen  that 
when  the  head  of  the  bone  has  thus  been  made  to  slip  from 
side  to  side,  rotation  becomes  a  less  efficient  manoeuvre  for 
reduction,  —  the  bone  tending  at  the  critical  moment  to  slip 
laterally  away  from  the  socket  instead  of  into  it,  especially 
where  the  rim  of  the  acetabulum  is  prominent,  or  the  Y  liga- 
ment is  relaxed.  It  is  here  that  vertical  traction,  sudden  or 
continued,  is  especially  to  be  relied  on.  This  will  be  further 
explained. 

FRACTURE    OF   THE   NECK. 

Except  in  a  very  old  subject,  no  apprehension  need  be  felt 
of  fracture  from  tolerably  skilful  manipulation,  or  from  cir- 
cumduction with  a  view  to  tearing  the  capsule.  The  femur 
has,  indeed,  in  rare  instances  been  fractured  by  manipulation 
as  well  as  by  pulleys  ;  ^  and  if  the  head  of  the  bone  be  forced 
into  a  position  where  it  is  confined  by  the  Y  ligament,  and 
from  which  it  cannot  escape,  it  will  be  acted  upon  with  great 
power  by  the  shaft  serving  as  the  long  arm  of  a  lever,  if  force 
be  still  indiscreetly  applied. 

FLEXION,   EXTENSION,    ADDUCTION,    ABDUCTION,    AND   ROTATION. 

Of  these  terms  the  last  two  alone  require  notice.  If  a 
thigh  abducted  at  a  right  angle  be  rotated  outward,  with  the 
knee  bent,  this  position  of   the   limb   has   been    sometimes 

1  Yerneuil  relates  a  case  of  fracture  resulting  from  an  attempt  to 
reduce  a  dislocation  on  the  pubes  in  a  man  eighty-one  years  of  age,  but 
only  after  the  bone  had  resisted  many  attempts  at  reduction.  (Medical 
Times  and  Gazette,  December,  1865,  p.  661.)  Similar  cases  have  been 
reported  of  fracture  from  the  use  both  of  manipulation  and  of  pulleys. 
(See  Cooper's  "Treatise  on  Dislocations  and  Fractures  of  the  Joints," 
Case  XXXVIL) 


DISLOCATION  OF  THE  HIP.  35 

erroneously   described   as   one   of    flexion.      It  becomes   so 
only  as  the  knee  is  brought  forward. 

Rotation  is  here  always  intended  to  apply  to  the  thigh, 
the  inward  or  outward  rotation  of  which,  in  a  limb  bent 
for  reduction,  carries  the  foot  in  an  opposite  direction,  and 
may  thus  lead  to  doubt.^ 

CIRCUMDUCTION. 

When  the  patient  lies  on  the  floor,  circumduction  carries 
the  knee  of  the  dislocated  limb  through  arcs  of  a  horizontal 
circle  of  which  the  Y  ligament  is  the  centre.  In  attempting 
reduction,  the  direction  of  this  motion  is  of  primary  impor- 
tance, as  well  as  the  point  at  which  it  begins.  The  following 
varieties  of  circumduction  should  be  distinguished  from  one 
another  :  — 

Circumduction  of  the  extended  thigh,  outward  (continued  by) 

''  "         flexed  '*        inward. 

Circumduction  of  the  extended     *'       inward  (continued  by) 

"  "         flexed  "       outward. 

The  patella  here  always  faces  to  the  front.  If  it  inclines 
outward  or  inward,  rotation  has  been  added  to  circumduction. 


REGULAR   DISLOCATIONS. 

DISLOCATION   UPON   THE   DORSUM   ILII. 

The  dorsal  dislocations  having  a  mutual  resemblance, 
resulting  from  the  regular  outline  of  the  bone  upon  which 
they   rest,  may  be  more   readily  grouped   than  the   others. 

^  The  thigh,  abducted  and  a  little  flexed,  was  rotated  inward;  the 
leg  and  the  foot,  on  the  contrary,  were  in  forced  rotation  outward. — 
Ollivier  :  Archives  de  Medecine,  1823,  torn.  Hi.  p.  545. 


36  DOKSAL  DISLOCATION. 

They  are  found  at  various  points  of  the  continuously  curved 
surface  of  the  os  innominatum,  from  the  tuberosity  of  the 
ischium  to  the  hollow  of  the  ilium,  —  with  the  articular 
head  well  down  beneath  the  external  obturator  muscle,  or 
farther  back  in  the  same  muscular  interstice,  behind  the 
tendon  of  the  internal  obturator,  or  emerging  above  this 
tendon  between  it  and  the  pyriformis  muscle,  or,  lastly, 
above  the  pyriformis. 

When  the  femur  is  flexed  at  right  angles,  and  thrust  directly 
backward,  it  tends  to  pass  between  the  obturator  interims 
and  the  pyriformis.  At  an  angle  of  forty-five  degrees  it  may 
be  thrust  upward  above  the  pyriformis,  while  in  extreme  flex- 
ion it  is  directed  downward  and  outward  toward  the  tuber- 
osity and  between  the  obturators.  Inward  rotation  luxates 
the  bone  at  lower  points,  even  though  the  limb  be  flexed  at 
the  same  angles. 

The  dislocation  below  the  internal  obturator  tendon  and  the 
subjacent  capsule  is  probably  common,  because  the  neck  of  the 
femur  is  here  first  arrested  in  its  ascent  from  the  frequent 
downward  displacement  which  occurs  while  the  limb  is  flexed, 
as  it  is  in  the  great  majority  of  such  accidents.  The  disloca- 
tion between  this  muscle  and  the  pyriformis  and  the  one 
above  the  pyriformis  may  be  assumed  to  be  more  rare,  these 
muscular  fibres  being  probably  more  often  torn  ;  but  future 
autopsies  can  alone  show  how  often  the  other  small  outward 
rotators  are  lacerated  ^  in  the  dorsal  dislocation,  when  the 
internal  obturator  with  its  capsule  has  yielded,  —  or,  indeed, 
how  often  the  head  of  the  bone  escapes  above  the  internal 

1  In  an  autopsy  of  dorsal  dislocation  by  iSlx.  Todd  (see  Cooper's 
"  Treatise,"  Case  XL. ;  also  Dublin  Hospital  Reports,  1822,  vol.  iii. 
p.  396),  the  dislocated  extremity  of  the  femur  had  occupied  a  large 
cavity  between  the  gluteus  maximus  and  medius ;  the  pyriformis, 
gemeUi,  obturatores,  and  quadratus  were  completely  torn  across ;  the 
iliacus,  psoas,  and  adductors  were  uninjured ;  the  orbicular  ligament 
was  entire  at  the  anterior  superior  parts  only. 


DOKSAL  DISLOCATION. 


37 


obturator  tendon,  and  how  often  it  ruptures  it  in  reaching  the 
same  point. 

With  reference  to  reduction,  however,  these  are  not  ques- 
tions of  essential  importance. 

The    comparative    infrequency    of     /    /|  .^1 

autopsies  of  hip  dislocation,  while  it  .  '  f 

leaves  us  in  the  dark  upon  certain 
points  which  it  would  be  desirable 
to  have  elucidated,  bears  evidence  to 
the  fact  that  this  lesion  is  not  a  se- 
vere one.  There  can  be  little  doubt 
that  the  small  rotators  near  the  joint 
are  lacerated  with  comparative  impu- 
nity, both  by  luxations  and  by  their 
reduction.  They  may  exert  some  in- 
fluence upon  the  relative  difficulty  of 
reduction  in  different  cases,  and  (as 
will  hereafter  be  shown)  the  mutual 
conversion  of  the  different  varieties 
of  dorsal  luxation  one  into  another 
probably  depends  upon  the  laceration 
of  these  different  muscles,  as  well  as 
upon  that  of  the  capsule.  Fig.  4.1 


SIGNS. 

In  this  dislocation  the  limb  is  moderately  inverted,  a  little 
shortened,  and  advanced.  The  toes  cross  the  toes  or  the 
instep  of  the  other  foot,  according  to  the  degree  of  flexion 
and  inversion,  and  the  head  of  the  bone  may  generally  be 
felt  upon  the  dorsum. 


^  Dorsal  dislocation,  showing  the  limb  inverted,  the  toes  crossing  those 
of  the  other  foot.  The  leg  has  been  well  brought  down,  and  exhibits 
but  little  flexion.  (See  p.  41  of  this  volume.)  It  is  often  more  flexed. 
(See  Figs.  11,  13,  and  p.  102  of  this  volume.) 


38  DORSAL  DISLOCATION. 

The  inversion  is  chiefly  due  to  the  outer  branch  of  the  Y 
ligament,  as  is  shown  by  the  fact  that  the  characteristic  sign 
disappears  when  this  branch  is  divided.^  But  other  parts  of 
the  capsule,  varying  with  its  laceration,  may  assist  the  inver- 
sion of  the  limb ;  and  when  the  latter  is  exaggerated,  as  when 

one  thigh  crosses  the  other 
at  its  middle  or  upper 
third,  they  may  seem  to  be 
largely  concerned  in  it. 
Thus,  if  the  dorsal  luxa- 
tion is  secondary  to  one 
below  the  socket,  only  the 
anterior  and  superior  fibres 
will  remain  untorn;  while 
if  the  femur  has  been 
thrust  obliquely  upward 
and  backward,  attach- 
ments may  be  found  at 
both  the  anterior  and  in- 
ferior margins  of  the  ace- 
tabulum.    But  it  is  unne- 

^       „  cessary  to  consider  these 

Fig.  5.2  -^ 

lesser  and  comparatively 
slender  fibres.  In  such  cases  the  knee  can  be  depressed,  as 
indeed  it  often  is,  by  the  forces  to  which  it  is  subjected  at 
the  time  of  the  accident,  until  the  exaggerated  flexion  and 
inversion  have  disappeared  ;  and  if  even  a  large  part  of  the 
capsule,  as  shown  in  Fig.  5,  is  stretched  tense  across  the 
socket,  it  may  then  be  ruptured  without  diminishing  the  in- 

^  For  an  illustration  of  the  condition  of  the  anterior  part  of  the 
capsule  in  a  congenital  dorsal  luxation  of  this  character,  see  Malgaigne's 
"Traite  des  Fractures  et  des  Luxations"  (Paris,  1847.    PI.  XXVIII.  Fig.  1). 

2  Dorsal  dislocation,  showing  a  comparatively  sound  capsular  liga- 
ment.    For  the  dissected  Y  ligament,  see  Figs.  6,  7. 


DORSAL   DISLOCATION. 


39 


version,  which  for  all  practical  purposes  is  due  to  the  outer 
branch  of  the  Y  ligament.  Upon  this,  in  fact,  inversion 
ultimately  depends  ;  without  its  rupture  there  can  be  no  ever- 
sion,  and  after  its  laceration  the  other  fibres  of  the  capsule 
liave  comparatively  little  strength.  The  rupture  of  the  inner 
branch  of  the  Y  lig- 
ament does  not  ma- 
terially change  the 
attitude  of  the  limb. 
The  shortening  va- 
ries with  the  position 
of  the  head  of  the 
bone.  Sometimes 
there  is  little ;  some- 
times  it  amounts 
apparently  to  two 
inches  or  more ;  but, 
as  Malgaigne  re- 
marks, it  is  then 
complicated  by  flex- 
ion, and  is  more  ap- 
parent than  real.i 

The  accompany- 
ing figures  (6  and  7)  are  intended  to  illustrate   the   opera- 
tion of  the  Y  ligament  in  limiting  the  range  of  the  femur, 
and  the  consequent   amount  of   shortening.      At  its   lowest 
point,  the  head  of  the  bone  corresponds  to  the  lower  part  of 

*  The  elongation  or  shortening  of  a  dislocated  thigh  may,  like  that  of 
the  arm,  be  real  or  only  apparent.  If  the  head  of  the  bone  is  luxated 
downward,  the  limb  should  be  longer ;  but  flexion  or  abduction  of  the 
shaft  ajiproximates  the  usual  points  of  measurement.  To  this  source  of 
error  should  be  added  the  tilting  of  the  pelvis  in  the  femoral  luxations. 

-  Figs.  6  and  7,  — dorsal  dislocation.  These  two  figures  are  intended 
to  show  the  possible  range  of  the  dissected  femur  when  limited  by  the 
Y  ligament  alone.     (From  photographs  taken  in  1861.) 


Fig.  6.2 


40 


DORSAL  DISLOCATION. 


the  ischiatic  notch,  while  it  may  rise  upon  the  dorsum  about 
an  inch  and  a  quarter  above  it.  The  former  position  is  that 
most  frequently  occupied  in  dorsal  luxations,  the  head  of  the 
bone  being  usually  confined  to  the  neighborhood  of  the  socket 
by  the  unruptured  muscles  and  by  the  capsular  and  Y  liga- 
ments (see  Fig.  5). 
Should  the  femur 
have  been  thrust  up- 
ward to  a  higher 
point,  it  might  again 
gravitate  to  the  level 
of  the  ischiatic  notch 
unless  engaged  in 
the  interstices  of  the 
small  rotators.  From 
examination  of  eleven 
specimens  of  dorsal 
dislocation,  Mal- 
gaigne^  infers  that 
the  head  of  the  fe- 
mur generally  corre- 
sponds to  the  ischi- 
atic notch,  and  that 
the  iliac  luxation  of  Cooper  is  a  pure  hypothesis,  while  his 
plate  illustrating  it  is  imaginary.  It  will  be  observed  that  the 
dorsal  dislocations  here  given  in  woodcuts  from  photographs 
exhibit  an  inconsiderable  shortening. 

If,  then,  there  be  a  fixed  inversion  of  the  limb  with  shorten- 
ing, and  the  head  of  the  femur  is  felt  upon  the  dorsum,  little 
desirable  information  is  to  be  gained  by  measurement  unless 
in  exceptional  or  doubtful  cases,  inasmuch  as  a  primary  dislo- 
cation upon  the  dorsum  practically  signifies  one  and  the  same 
thing,  whether  directly  backward  behind  the  acetabulum,  or 

1  Traite,  etc.,  p.  820. 


Fig.  7. 


DORSAL  DISLOCATION.  41 

obliquely  upward  and  backward  to  the  full  extent  of  the  Y 
ligament,  if  this  remain  unbroken.  A  more  useful  indication 
is  the  degree  of  its  mobility. 

The  thigh  can  always  be  flexed,  and  then  its  mobility  varies 
with  the  extent  of  the  laceration  of  the  capsule  and  the  adja- 
cent tissues  which  bind  the  neck  of  the  femur  to  the  pelvis,  — 
an  important  point,  best  determined  by  the  extent  to  which 
the  flexed  limb  can  be  abducted.  If  the  bone  has  escaped  by 
a  large  aperture  in  the  capsule,  perhaps  with  rupture  of  the 
obturator  tendon,  there  will  be  a  comparative  freedom  of 
motion  and  less  inversion ;  while  if  the  laceration  is  small, 
the  movement  will  be  restricted  and  the  limb  comparatively 
rigid. 

By  flexing  and  rotating  the  thigh,  the  head  of  the  bone  may 
be  felt  upon  the  ilium,  unless  the  patient  is  very  fleshy  or  the 
parts  are  greatly  swollen ;  but  when  this  sign  is  wanting,  a 
differential  diagnosis  can  be  based  on  other  indications.  Thus, 
although  it  is  practically  needless  to  distinguish  the  dorsal  dis- 
location from  the  one  below  the  tendon,  the  latter  is  generally 
characterized  by  a  more  advanced  position  of  the  knee,  the 
limb  being  more  inverted,  and  crossing  the  sound  thigh  at  a 
higher  point.  On  the  other  hand,  the  other  regular  disloca- 
tions and  the  fractures  exhibit  eversion,  if  we  except  the 
fracture  of  the  neck  accompanied  by  inversion,^ —  an  accident 
so  rare  that  it  need  liardly  be  taken  into  account,  —  and  some 
of  the  fractures  of  the  pelvis. 

In  the  dorsal  dislocation,  however  much  the  knee  may  be 
advanced  and  the  leg  inverted,  even  when  the  head  of  the 
femur  is  below  the  tendon,  the  thigh  may  be  depressed  by 
manipulation  until  the  knees  lie  almost  upon  the  same  plane ; 
and  in  some  cases,  —  where,  as  in  a  female,  the  legs  are  knock- 
kneed,  or  where  the  knee-joint  is  loosely  articulated,  or  in  an 

1  See  p.  147  of  this  volume ;  and  also  a  Practical  Treatise  on  Fractures 
and  Dislocations  (p.  354).     By  Frank  Hastings  Hamilton,  M.  D.,  etc. 


42  DORSAL  DISLOCATION. 

old  dislocation,  —  the  foot  may  seem  not  to  be  inverted.  But 
the  inversion  of  the  patella,  and  especially  tlie  degree  of 
resistance  in  everting  the  foot,  betray  the  still  unreduced 
luxation,  even  when  the  position  of  the  limb  has  been  much 
improved  by  efforts  at  reduction,  which,  though  unsuccessful, 
have  lacerated  the  capsule  and  loosened  the  muscles.  This  is 
especially  true  in  the  case  of  a  fleshy  subject,  where  the  marks 
are  obscure. 

DORSAL   DISLOCATIONS    BETWEEN    THE   ROTATOR   MUSCLES. 

It  has  been  said  that  the  dorsal  dislocation  is  often  second- 
ary, the  head  of  the  femur  having  first  escaped  below  the 
socket.  But  the  head  of  the  bone  may  also  reach  the  dorsum 
at  once  by  a  backward  thrust  in  the  direction  of  its  axis, 
which  is  also  likely  to  engage  the  head  in  the  muscular  inter- 
stices of  the  rotators.  Autopsies  have  hitherto  failed  to  show 
whether  in  such  a  high  dorsal  dislocation  the  internal  obtu- 
rator, with  other  inward  rotators,  is  usually  ruptured,  or 
whether  the  head  of  the  bone  usually  emerges  above  the 
internal  obturator ;  but  I  have  expressed  the  belief  that  the 
outward  rotators  are  often  ruptured,  both  by  the  original 
injury  and  by  the  protracted  manipulation  accompanying  the 
use  of  pulleys,  and  that  this  lesion  is  by  no  means  serious. 
It  may,  indeed,  be  difficult  to  distinguish  between  the  flexion 
and  inversion  of  a  femur  engaged  above  the  obturator  muscle 
and  those  of  one  in  the  act  of  ascending  from  the  position  of 
a  luxation  near  the  tuberosity  to  that  below  the  tendon.  But 
this  distinction  is  practically  unimportant,  since,  by  circum- 
duction of  the  limb,  a  way  can  be  cleared  for  the  head  of  the 
bone  from  any  point  of  the  dorsum  within  the  range  of  the  Y 
ligament  round  to  the  thyroid  foramen. 

The  head  of  the  femur  has  been  found  between  the  obturator 
internus  and  the  pyriformis,  which  lies  above  it,  and  has  even 
passed  still  higher  beneath  the  pyriformis,  emerging  between 


DORSAL  DISLOCATION.  43 

it  and  the  gluteus  minimus.^     The  bone  is  then  drawn  so  far 
backward  by  the  obturator  tendon  that  the  outer  branch  of 

1  See  an  interesting  case  mentioned  by  M.  Parmentier  (Bulletin  de  la 
Societe  Anatomique,  1850,  p.  177).  The  limb  was  "adducted  and  short- 
ened three  quarters  of  an  inch.  The  femur  was  luxated  between  the 
pyiiformis  muscle  and  the  obturator  internus,  the  head  reaching  to  the 
ischiatic  spine.  The  button-hole  thus  formed  opposed  the  i-eduction  of 
the  luxation  in  the  dissected  specimen."  Another  interesting  and  excep- 
tional case  has  been  reported  by  Dr.  Servier.  (See  Bulletin  de  la  Societe 
de  Chirurgie,  1863,  p.  485.  Report  of  M.  Legouest.)  The  head  of  the  femur, 
instead  of  escaping  between  the  obturator  internus  and  pyi'iformis  mus- 
cles, as  in  the  case  described  by  M.  Parmentier,  was  here  found  above 
the  pyriformis,  between  this  muscle  and  the  gluteus  minimus.  The  signs, 
so  far  as  can  be  judged  from  the  account  given,  were  those  of  the  dorsal 
luxation.  The  capsule  was  ruptured  posteriorly.  It  has  been  remarked 
that  there  is  great  difficulty  in  producing  these  liixations  in  the  dissected 
specimen  without  rupturing  the  slender  outward  rotators  ;  but  if  the  head 
is  made  to  emerge  between  them,  either  by  rotation  or  by  a  direct  back- 
ward thrust  of  the  shaft,  it  is  so  embraced  by  the  muscles,  and  also  by 
the  capsular  orifice,  which  is  then  likely  to  be  small,  that  the  movements 
of  the  limb  are  comparatively  restricted,  and  the  muscular  obstacle  to 
their  reduction  may  be  considerable.  I  do  not  know  how  siich  cases  can 
be  identified  with  certainty  during  life.  If  the  head  of  the  bone  has 
escaped  by  rotation  of  the  shaft  inwards,  it  may  perhaps  be  reduced  by 
outward  rotation,  with  previous  or  subsequent  flexion  of  the  thigh,  and 
thus  brought  to  a  point  below  the  socket ;  although  the  surer  way  is  to 
take  the  risk  of  rupturing  all  these  smaller  muscles  by  outwai'd  circum- 
duction of  the  flexed  limb,  accompanied  with  outward  rotation,  and  then 
to  reduce  the  bone  as  usual. 

M.  Guersant  (Notices  sur  la  Chirurgie  des  Enfants,  Paris,  1864-77), 
reporting  two  cases  which  occurred  under  his  own  obsei'vation,  and  refer- 
ring to  a  paper  of  M.  Chapplain,  proposes  a  distinction  between  superficial 
and  deep  iliac  luxations.  Such  a  difference  would  be  difficult  to  discover 
in  practice,  either  in  a  fleshy  or  a  thin  subject,  but  may  have  some  foun- 
dation in  the  muscular  complications  just  alluded  to.  Mr.  Wormald 
reports  a  case  of  dislocation,  originally  on  the  ilium,  in  which,  by  the  use 
of  pulleys,  the  bone  was  "  thrown  "  upon  the  sciatic  notch,  whence  it  "  could 
not  be  reduced."  (Medical  Times  and  Gazette,  Aug.  16,  1856,  p.  170.)  I 
am  at  a  loss  to  explain  this  case,  if  the  facts  are  accurately  given,  except 
upon  the  hypothesis  that  muscular  button-holes,  together  with  horizontal 
extension,  determined  the  result. 

In  a  case  of  "  Dislocation  of  the  Thigh-Bone  upward  and  backward, 


44  DOESAL  DISLOCATION. 

the  Y  becomes  very  tense,  producing  great  inversion  in  the 
extended  limb,  and  adduction  when  it  is  flexed,  the  obturator 
limiting  inversion.  The  occurrence,  during  life,  of  these  vari- 
eties of  dorsal  luxation  having  been  well  attested,  it  is  possible 
that  they  are  comparatively  common,  and  that  many  dorsal 
luxations  occur  above  the  internal  obturator  tendon, —  a  con- 
dition which  would  explain  the  reported  "  change  "  by  pulleys 
of  the  "  dorsal "  dislocation  into  that  "  upon  the  sciatic  notch," 
when  the  limb  was  drawn  down.  The  subjoined  methods  will 
accomplish  their  reduction  before,  or  at  any  rate  after,  the 
rupture  of  the  internal  obturator ;  and  this  muscle  may  be 
ruptured  at  Avill. 

The  strong  outer  or  posterior  part  of  the  capsule,  which 
offers  a  resistance  nearly  in  the  direction  of  the  obturator 
tendon,  may  also  be  torn  by  circumduction,  —  the  capsule  re- 
quiring less  effort  for  its  rupture  than  the  muscles,  being 
inserted  at  the  base  of  the  neck,  nearer  to  the  centre  of 
rotation. 

REDUCTION    OF   THE    DISLOCATION   UPON   THE   DORSUM. 

This  dislocation  may  be  equally  well  reduced  by  traction  or 
rotation.^ 

primarily  on  the  Dorsum  Ilii,  secondarily  on  the  Sciatic  Notch  "  (James 
Syme,  F.  R.  S.  E.,  etc.,  Contributions  to  Pathology  and  the  Practice  of  Sur- 
gery, p.  277),  the  following  passage  occurs :  "  That  excellent  authority,  Sir 
Astley  Cooper,  though  he  has  warned  against  the  risk  of  this  occurrence 
in  reducing  dislocation  into  the  foramen  ovale,  has  not  noticed  it  with 
regard  to  the  more  common  case  of  dislocation  on  the  ilium."  Some- 
thing must  be  allowed  for  a  conventional  surgical  prejudice  against  the 
"  sciatic  notch,"  which  labors  under  a  bad  name. 

1  In  experiments  upon  the  dead  subject,  I  have  twice  found  that  the 
femur,  after  reduction  by  rotation,  had  accidentally  engaged  the  sciatic 
nerve  upon  the  front  of  its  neck.  The  limb  was  flexed,  inverted,  and 
a  little  abducted,  and  the  nerve  tense  and  projecting  in  the  popliteal 
space,  as  in  a  case  of  old  contraction  of  the  knee-joint.  This  would  not 
have  occurred  if  the  weight  of  the  limb  had  been  properly  sustained. 


DOKSAL  DISLOCATION. 


45 


By  Traction.  —  1.  Lay  the  patient,  when  etherized,  on  his 
back  upon  the  floor,  bend  the  hmb  at  the  knee,  flex  the  thigh 
upon  the  abdomen,  adduct  and  rotate  it  a  little  inward,  to  dis- 
engage the  head  of  the  bone  from  behind  the  socket.  The  Y 
ligament  is  then  relaxed.     (Fig.  8.) 

If  the  bone  can  now  be  abducted  beyond  the  perpendicular, 
the  capsule  and  other  tissues  are  probably  so  torn  or  relaxed 
that  reduction  may  be  accomplished  without  much  difficulty ; 
the  thigh  need  only  be  forcibly  lifted  or  jerked  toward  the 
ceiling,  with  a  little  simultaneous  circumduction  and  rotation 
outward,  to  direct  the  head  of  tlie  bone  toward  the  socket. 

2.  The  surgeon's  foot^  may  be  placed  on  the  anterior  supe- 
rior spinous  process  of  the  ilium,  or  on  the  pubes,  to  keep  the 
pelvis  down,  while 

he  pulls  the  flexed 
knee  up.  Or  in  the 
same  way,  while 
assistants  suspend 
the  pelvis  a  few 
inches  from  the 
floor  by  a  strip  of 
board  passed  trans- 
versely under  the 
calf  near  the  ham, 
the  surgeon  may 
with  his  foot  thrust 
the  pelvis  down 
into  its  place. 

3.  Flex  the  thigh  and  circumduct  it  outward,  across  the 
abdomen.  When  it  forms  a  large  angle  laterally  with  the 
trunk,  the  head  of  the  bone,  if  it  has  not  snapped  into  its 

1  Divested,  it  need  hardly  be  said,  of  boot  or  shoe. 

2  Dorsal  dislocation.  The  result  of  flexion  in  relaxing  the  Y  ligament. 
(From  a  photograph  taken  in  1861.)  > 


Fig.  8.2 


46 


DORSAL  DISLOCATION. 


place,  is  in  or  near  the  thyroid  foramen.  The  rent  in  the 
capsule  being  thus  enlarged,  restore  the  thigh  to  a  perpen- 
dicular, and  proceed  as  in  the  last  method. 

4.  Place  the  patient  face  downward  on  a  table,  the  thigh, 
flexed  at  right  angles,  hanging  over  its  edge,  and  bear  the 
limb  downward,  with  or  without  rotation.^ 


Fig.  9.^ 


By  Rotation.  —  Flex  the  thigh  and  abduct  or  circumduct  it 
outward,  at  the  same  time  rotating  it  outward.  The  head  of 
the  bone,  revolving  about  the  great  trochanter,  which  is  fixed 


^  A  little  girl  of  twelve  years,  upon  whom  six  or  seven  attempts  of  an 
hour  each  had  been  made  to  reduce  this  luxation  by  straight  extension, 
was  thus  placed  on  a  board,  when  the  head  of  the  femur  immediately 
slipped  in.     (Collin,  These  Inaugurale.     Montpellier,  1833.) 

In  1830  Colombot  had  employed  this  method  with  rotation.  (Docu- 
ments sur  la  ]\Iethode  Osteotropique.     Paris,  1840.) 

2  Dorsal  dislocation.  Reduction  by  rotation.  The  limb  has  been 
flexed  and  abducted,  and  it  remains  only  to  evert  it,  and  render  the 
outer  branch  of  the  Y  ligament  tense  by  rotation. 


DORSAL  DISLOCATION.  47 

by  the  outer  branch  of  the  Y  ligament,  rises  over  the  edge  of 
the  socket  into  its  place  unless  the  capsule  is  interposed,  in 
which  case  enlarge  the  opening,  as  in  the  third  method.  This 
is  a  very  effective  manoeuvre  for  the  reduction  of  the  dorsal 
luxations,  and  has  been  described  in  the  words,  "Lift  up, 
bend  out,  roll  out."  An  imperfect  comprehension  of  this 
empirical  rule  has  led  to  confusion  in  its  application.^  It 
should  be  remembered  that  if  the  thigh  is  everted  before 
it  is  abducted,  it  may  be  locked  below  the  socket.  For  this 
reason  it  is  well,  especially  in  an  old  dislocation  where  the 
parts  are  unyielding,  to  invert  the  limb  until  the  final  abduc- 
tion, when  it  may  be  everted. 

When  the  thigh  is  forcibly  flexed  upon  the  abdomen,  the 
head  of  the  bone  is  lifted  out  from  beneath  the  socket.^  A 
little  inward  rotation  favors  the  same  result.  If  the  thigh  be 
now  slowly  abducted  or   depressed   outward,  it  is  plain  that 

1  An  English  journal  terms  this  method  "  a  knack."  Mr.  Cock,  in  a 
case  of  dorsal  dislocation,  gives  the  rule,  "  Lift  up,  bend  out,  roll  in  " 
(Medical  Times  and  Gazette,  June  30,  1855,  p.  644),  —  a  nianceuvi-e 
which  may  succeed,  although  the  method,  also  mentioned  by  INIr.  Cock, 
of  flexion,  abduction,  and  rotation  outward,  is  perhaps  the  more  correct 
one.     (Lancet,  July  7,  1855,  p.  6.) 

The  thigh  being  flexed,  outward  rotation  and  outward  circumduction 
both  carry  the  head  of  the  bone  toward  the  socket. 

In  a  case  of  dorsal  dislocation  reported  by  ]\Ir.  W.  J.  Square,  j)ul- 
leys  were  applied  for  twenty-five  minutes  unsuccessfully;  and  again 
twenty-five  minutes  longer,  with  no  better  result,  when  they  were  aban- 
doned. The  thigh  was  now  flexed  at  right  angles,  and  easily  reduced 
by  circumduction  outward.  (Medical  Times  and  Gazette,  Nov.  13, 
1858,  and  American  Journal  of  the  Medical  Sciences,  January,  1859, 
p.  2.58.) 

2  Dr.  George  Sutton  of  Aui'ora,  Ind.,  relates  a  case  of  dorsal  dislocation 
in  which,  after  a  failure  from  some  cause  to  reduce  the  hip  by  the  ordi- 
nary flexion  method,  a  roll  of  cloth  was  placed  in  the  groin,  as  a  fulcrum, 
by  which  the  head  of  the  flexed  femur  was  pried  out  from  beneath  the 
socket,  and  afterward  reduced  by  abduction  while  the  limb  was  lifted. 
(Western  Journal  of  Medicine  and  Surgery,  September,  1868.  American 
Journal  of  the  Medical  Sciences,  October,  1868,  p.  588.) 


48  DORSAL  DISLOCATION. 

the  head  of  the  bone,  suspended  by  the  Y  ligament,  must  rise 
toward  the  socket ;  and  that  when  the  shaft  is  thus  abducted, 
outward  rotation  assists  the  entrance  of  the  head.  If  the  head 
of  the  bone  is  above  the  tendon  of  the  internal  obturator,  this 
outward  circumduction  also  ruptures  the  small  rotator  muscles. 
It  may  be  needless  to  say  that  were  the  head  of  the  bone  sus- 
pended by  the  dissected  Y  ligament  alone,  as  shown  in  some 
of  the  annexed  woodcuts,  a  lateral  movement  of  the  knee 
would  perhaps  cause  the  head  of  the  bone  to  swing  from  side 
to  side,  instead  of  giving  to  it  the  desired  upward  tilt.  This 
movement  is  hindered  by  the  unruptured  fibres  of  the  capsule 
on  each  side  of  the  Y  ligament,  which  continue  to  a  greater  or 
less  extent  in  the  different  dislocations,  and  contribute  to  the 
varying  facility  with  which  different  cases  are  reduced.  This 
is  especially  true  of  the  dislocation  behind  the  tendon  of  the 
obturator  internus,  where  the  posterior  part  of  the  capsule  not 
unfrequently  remains  uninjured. 

I  have  thus  reduced  the  dislocated  femur  in  living  subjects 
by  a  single  slow  circumduction  occupying  from  a  quarter  to 
half  a  minute,  and  also  by  a  first  rapid  sweep  of  two  seconds. 
The  manoeuvre  may  be  perfectly  accomplished  without  lifting 
the  limb  toward  the  ceiling,  but  is  more  effectual  when  ter- 
minated with  an  upward  jerk.^  If  it  fails,  repeat  the  process 
once  or  twice,  and  then,  if  necessary,  enlarge  the  opening. 
Or  if  the  limb  is  too  much  flexed,  and  the  Y  ligament  too 
much  relaxed,  then  the  limb  may  be  slowly  extended  from 
the  perpendicular  position,  when,  as  the  Y  ligament  becomes 

1  This  upward  jerk  is  a  very  efficient  manceuvi'e,  both  alone  and  when 
assisted  by  rotation.  Annibal  Parea  is  said  to  have  availed  himself  of  it. 
"  He  placed  the  patient  on  his  back,  the  pelvis  being  confined  by  assist- 
ants ;  he  flexed  the  knee,  raised  the  thigh  almost  vertically,  grasped  its 
lower  extremity  with  both  hands,  gave  it  a  jerk  as  if  to  raise  it  perpen- 
dicularly, and  the  luxation  was  instantaneously  reduced."  (Malgaigne's 
"  Traite,"  etc.,  p.  823.) 


DORSAL  DISLOCATION.  49 

tightened,  the  head  of  the  femur  will  rise  into  its  place  (see 
p.  31),^  especially  if  the  weight  of  the  limb  be  sustained  by 
the  operator.  The  flexed  femur  is  thus  reduced  by  abduction 
and  rotation  with  less  flexion.^ 

If  the  laceration  is  large,  and  the  head  of  the  bone  inclines 
to  slip  toward  the  thyroid  foramen  during  abduction,  this  ten- 
dency is  easily  counteracted  by  the  upward  jerk  or  lift  already 
described.  But  if  upon  examination  the  flexed  thigh  cannot  be 
abducted  beyond  the  perpendicular,  the  head  of  the  bone  has 
either  escaped  by  a  small  orifice  in  the  capsule  (which  is  then 
comparatively  sound),  or  has  also  passed  above  the  obturator 
or  pyriformis  (which  are  then  unbroken),  and  is  suspended  just 
behind  the  edge  of  the  socket,  midway  between  these  muscles 
and  the  Y  ligament.  In  the  former  case  the  luxation  may 
perhaps  be  reduced  by  flexion  with  abduction  and  outward 
rotation ;  in  the  latter,  it  is  possible,  but  not  easy,  to  disen- 
gage it  by  traction  across  the  symphysis,  the  bone  being  lifted 
by  a  towel  round  the  thigh  at  its  upper  part.^  If  these  attempts 
do  not  succeed,  the  obturator  muscle  and  the  capsule  can  be 

^  See  a  case  of  "  ischiatic  "  dislocation  treated  in  this  way  by  Greorge 
W.  Callender,  Esq.,  Assistant  Surgeon  and  Lecturer  on  Anatomy  at  St. 
Bartholomew's  Hospital.  (Lancet,  March  14,  1868,  p.  343.)  Mr.  Callen- 
der believes,  however,  that  the  capsule  "  never  can  offer  any  obstacle  to 
the  reduction  of  dislocations  of  the  hip." 

2  In  the  extreme  flexed  position  of  the  limb,  the  Y  ligament  is  so  re- 
laxed that  it  may  not  afford  a  firm  centre  of  rotation.  (See  p.  34  of  this 
volume.)  A  case  reported  by  IVIr.  Jones  (Medical  Times  and  Gazette, 
April,  1856,  p.  362)  may  serve  to  illustrate  this  point.  In  reducing  a  dorsal 
dislocation,  the  thigh  was  flexed  as  far  as  possible,  abducted,  and  rotated 
outward.  The  attempt  failed ;  but  in  gTadually  bringing  the  limb  down 
while  the  same  forces  were  applied,  the  head  of  the  bone  snapped  into 
its  socket  when  the  thigh  had  reached  a  semi-flexed  position.  (See  also 
Mackenzie,  London  Hospital  Reports,  1866,  vol.  iii.  p.  207.) 

3  To  dislocate  the  bone  above  the  obturator  tendon  in  the  dead  sub- 
ject, the  posterior  capsule  should  be  divided  high  up  toward  the  Y 
ligament,  and  the  bone  then  strongly  flexed,  adducted,  and  rotated  out- 
ward.    By  inward  rotation  it  may  be  reduced. 

4 


50  DORSAL  DISLOCATION. 

ruptured  by  outward  circumduction  of  the  flexed  limb,  —  an 
expedient  also  to  be  resorted  to  whenever  the  limb  is  especially 
fixed  and  unyielding,  —  after  which  the  hip  may  be  reduced 
as  usual. 

The  following  case  will  illustrate  the  method  by  traction. 
I  was  requested  by  Dr.  E.  A.  W.  Harlow,  Oct.  5, 1861,  to  see, 
with  him,  a  stout,  middle-aged  Irishman  whose  hip  had  been 
dislocated  an  hour  or  two  before.  In  climbing  the  ladder  of 
a  freight  car  while  the  train  was  moving,  his  thigh  was  bent 
to  a  horizontal  position  just  in  time  to  be  caught  between  this 
car  and  the  next  one.  The  flexed  hip  was  thus  dislocated 
backward  primarily  upon  the  dorsum,  by  a  force  very  exactly 
applied  to  the  knee  in  front  and  the  pelvis  behind,  probably 
with  slight  laceration  of  the  capsule.  The  limb  was  short- 
ened, the  toes  were  firmly  inverted  across  the  instep  of  the 
other  foot,  the  head  of  the  femur  being  felt  upon  the  dorsum. 
On  flexion  the  thigh  could  not  be  abducted  as  far  as  the 
perpendicular,  and  was  unusually  immovable,  —  the  latter 
condition  being  perhaps  due  to  the  comparative  integrity  of 
the  capsule.  This  would  formerly  have  led  to  the  belief 
that  it  was  engaged  in  the  ischiatic  notch.  It  is  also  pos- 
sible that  the  head  of  the  femur  may  have  escaped  between 
the  Y  ligament  and  the  obturator  or  pyriformis  muscle.  The 
patient  being  etherized,  I  flexed  the  limb,  and  made  several 
efforts  to  reduce  it  by  angular  traction,  but  was  unable 
to  do  so,  the  failure  being  doubtless  due  to  the  small  size 
of  the  capsular  and  perhaps  the  muscular  opening,  which 
under  the  same  circumstances  I  should  now  not  hesitate  to 
enlarge  by  circumduction.  The  attempt  was  abandoned  till 
the  next  morning,  when,  the  patient  being  again  etherized 
and  the  limb  flexed  as  usual,  a  rectangular  metallic  splint 
was  applied  beneath  the  knee,  and  so  held  by  assistants  as 
to  suspend  the  pelvis  a  few  inches  from  the  floor.  I  then 
placed  my  foot  upon  the  anterior  superior  spine  of  the  pelvis, 


DORSAL   DISLOCATION.  51 

and  at  the  first  effort  depressed  the  latter  into  its  place. ^ 
During  the  patient's  stay  in  the  hospital  this  limb  was  a  little 
longer  than  the  other,  —  an  appearance  I  have  observed  in 
several  instances,  and  which  is  perhaps  due  to  a  portion  of 

1  I  venture  to  publish  the  following  note  from  Dr.  Mann,  of  Roxbury, 
in  illustration  of  the  above  manoeuvre :  — 

Roxbury,  Jan.  IG,  1867. 
Prof.  H.  J.  Bigelow  : 

Dear  Sir,  —  I  take  pleasure  iu  sending  you  the  following  brief  account  of  a 
case  of  dislocation  of  the  right  femur  upon  the  dorsum  ilii,  in  which  I  used  the 
method  for  its  reduction  pointed  out  by  you  at  the  annual  meeting  of  the  Massa- 
chusetts Medical  Society,  in  May,  1862.  At  that  time  you  demonstrated  a  liga- 
ment described  as  the  Y  ligament,  and  the  part  performed  by  it  in  giving  position 
to  the  limb  and  in  preventing  the  return  of  the  bone  to  its  socket,  together  with 
the  best  means  of  overcoming  that  resistance.  I  was  much  surprised  at  the  ease 
with  which  the  reduction  was  accomplished,  ...  for  I  am  sure  in  no  other  way 
could  it  have  been  accomplished  with  so  much  ease  to  the  patient  and  to  myself. 

I  was  called,  July  10,  1862,  to  James  Stump,  a  stout,  muscular  man,  about  fifty 
years  of  age,  who  while  picking  cherries  lost  his  hold  and  fell  from  the  tree,  a  dis- 
tance of  about  twenty  feet,  to  the  ground.  He  complained  of  great  pain  in  his 
hip,  and  was  incapable  of  rising.  He  was  picked  up  and  conveyed  to  his  home  (a 
distance  of  three  miles),  where  I  saw  him  about  an  hour  after  the  accident. 

I  found  him  lying  on  a  mattress  on  the  floor.  The  right  leg  was  two  inches 
shorter  than  the  left,  with  the  toes  resting  upon  the  opposite  instep,  the  knee  and 
foot  turned  inward,  and  a  little  advanced  upon  the  other.  The  limb  could  be 
bent  upon  the  other,  but  could  not  be  moved  outward.  The  trochanter  major 
could  be  felt  near  the  anterior  superior  spinous  process  of  the  ilium,  and  the  head 
of  the  bone  moving  upon  the  dorsum  ilii  during  rotation  of  the  knee  inward. 
He  was  just  in  the  position  I  desired,  and  I  determined  to  try  your  method  of 
reduction. 

Having  etherized  him,  I  placed  my  left  foot  (the  boot  having  been  removed  for 
that  purpose)  upon  the  pelvis  of  the  right  side,  and  bending  the  leg  of  the  patient 
upon  the  thigh,  and  the  thigh  upon  the  pelvis,  thus  relaxing  the  Y  ligament,  and 
placing  my  left  arm  under  the  knee,  and  grasping  the  ankle  with  the  right  hand, 
I  had  perfect  conmiand  of  the  limb. 

Keeping  the  pelvis  firmly  fixed  with  the  foot,  I  made  a  firm  and  pretty  forcible 
extension  with  the  left  arm,  and  with  a  slight  rotatory  movement  with  the  right 
hand  the  bone  instantly  slipped  into  its  socket  with  a  smart  snapping  noise 
which  could  be  distinctly  heard  by  every  one  in  the  room. 

In  two  days  the  patient  was  able  to  walk  about  his  room  and  resume  his  work 
(which  was  that  of  fancy-basket  maker).  I  met  him  upon  the  street  three  weeks 
after  the  accident,  and  he  assured  me  he  could  walk  as  well  as  ever,  saying  that 
he  had  walked  five  miles  that  afternoon  without  fatigue. 

Very  truly  yours,  Benjamin  Mann. 


52  DORSAL  DISLOCATION. 

the  capsule  being  engaged  between  the  head  of  the  bone  and 
the  acetabulum,  —  but  in  1869  it  was  shortened  half  an  inch, 
everted,  and  the  power  of  rotation  impaired,  apparently  by 
dry  chronic  arthritis.  In  another  case  which  I  have  lately 
examined,  of  dislocation  reduced  fifteen  years  ago  by  the  late 
Dr.  Hayward,  this  deformity  of  the  hip  from  the  same  cause 
was  much  more  strongly  marked. 

The  subject  of  the  following  case  of  dislocation  of  four 
weeks'  standing  was  sent  to  me  by  Dr.  Thomas,  of  Scituate. 

Four  weeks  ago  a  large  door,  weighing  half  a  ton,  fell  upon 
the  patient,  —  a  man,  aged  fifty,  —  dislocating  his  left  hip. 
An  irregular  practitioner  etherized  him,  and  with  the  assist- 
ance of  two  men  drew  the  leg  down,  and  told  him  that  it 
was  reduced.  The  left  leg  is  now  two  inches  shorter  than  the 
right,  the  foot  inverted  over  the  right  instep,  the  trochanter 
higher  and  more  prominent  than  it  should  be,  and  the  head 
of  the  bone  felt  upon  the  dorsum  ilii. 

The  reduction  was  effected  as  follows.  The  patient  was 
etherized  and  laid  upon  the  floor.  The  thigh  was  slowly 
flexed  upon  the  abdomen,  and  then  moved  laterally,  to  loosen 
the  tissues  about  the  joint.  It  was  then  returned  toward  the 
perpendicular,  and  jerked  upward,  with  a  little  simultaneous 
abduction  and  rotation  outward,  but  without  success.  Recog- 
nizing the  comparatively  untorn  or  reuniting  capsule  as  the 
cause  of  the  failure  of  this  effort,  I  slowly  circumducted  the 
flexed  thigh  outward  until  the  head  of  the  bone  was  carried 
from  the  dorsum  nearly  to  the  thyroid  foramen.  After  the 
capsular  orifice  was  thus  enlarged,  and  the  head  of  the  bone  re- 
placed below  the  socket,  the  first  upward  jerk  reduced  the  dis- 
location, —  the  whole  manipulation  having  occupied  scarcely 
a  minute  and  a  half. 

The  following  cases  were  reduced  by  rotation. 

In  the  first  case  the  reduction  was  easy,  and  occurred  in  the 
wards  of  Dr.  Cabot,  who  kindly  submitted  the  case  to  me. 


DORSAL  DISLOCATION.  53 

A  man,  aged  twenty-four,  had  his  left  hip  dislocated  by  the 
caving  in  of  a  bank  of  earth.  The  usual  signs  of  dislocation 
on  the  dorsum  were  presented.  To  reduce  it,  the  thigh  was 
flexed  to  a  perpendicular,  and  in  order  to  enlarge  the  capsular 
orifice  it  was  then  slowly  abducted  with  a  little  rotation  out- 
ward, during  which  it  snapped  into  its  place.  The  manoeuvre 
occupied  scarcely  ten  seconds. 

It  will  be  observed  that  this  movement  is  equally  suitable 
for  extending  the  capsular  laceration  in  the  direction  of  the 
thyroid  foramen,  or,  if  the  laceration  be  already  sufficient, 
for  prying  the  head  of  the  bone  into  the  socket,  with  the  aid 
of  the  Y  ligament  as  a  fulcrum. 

The  following  was  a  case  of  dorsal  dislocation  of  eight 
months'  standing,  which  had  occurred  in  consequence  of  a 
fall  on  the  floor.  The  patient,  a  woman  twenty-seven  years 
of  age,  had  remained  in  bed  for  several  months,  and  after- 
ward walked  with  great  difficulty.  The  limb  then  presented 
the  usual  signs  of  dorsal  dislocation,  and  was  reduced  by 
flexion,  abduction,  and  eversion.  I  first  saw  her  sixteen  days 
after  this  operation,  when  the  bone  had  again  become  dis- 
placed. The  limb  was  an  inch  or  more  shorter  than  its 
fellow ;  and  though  its  patella  looked  directly  forward,  and 
the  foot  was  not  inverted,  yet  the  latter  could  not  be  everted 
like  that  of  the  sound  limb,  and  the  head  of  the  bone  was 
felt  near  the  sciatic  notch.  By  forcible  flexion,  abduction, 
and  eversion  1  brought  the  head  of  the  bone  into  the  socket 
with  a  snap;  but  when  the  limb  was  again  extended,  a  very 
slight  inversion  sufficed  to  reproduce  the  dislocation,  —  in  fact, 
the  limb  could  not  be  trusted  to  itself.  After  the  bone  had 
thus  repeatedly  slipped  out,  the  patient  was  placed  in  bed  on 
her  back,  and  the  dislocation  again  reduced  by  flexion,  abduc- 
tion, and  eversion,  which  brought  the  flexed  thigh  and  knee 
down  to  the  mattress  on  their  outer  side.  The  knee  was 
then  tied  to  the  bedstead  in  this  position  with  a  towel,  and  the 


54  DORSAL  DISLOCATION. 

foot  secured  to  the  knee  of  the  sound  side  until  the  socket 
should  be  excavated  by  absorption.  In  two  weeks  she  was 
allowed  to  sit  up,  and  in  two  weeks  more  was  discharged, 
well.i 

In  the  following  case  of  dorsal  dislocation  of  the  hip  of  six 
weeks'  standing,  after  reduction  a  muscle  was  subcutaneously 
divided. 

The  patient  while  driving  a  railroad  hand-car  was  thrown 
upon  the  track  in  front  of  it,  the  car  passing  over  his  body. 
On  examination  under  ether,  the  head  of  the  femur  was  felt 
"  near  the  sciatic  notch."  After  the  thigh  was  flexed  and 
rotated  to  break  up  the  old  adhesions,  the  dislocation  was 
reduced  by  flexion,  abduction,  and  extension.  Eight  days 
after  this  operation  the  bone  had  again  slipped  out ;  and  at 
that  time  I  first  saw  the  patient,  and  made  the  following 
record  in  the  Hospital  books  (vol.  cxxxii.,  August,  1867) : 

"  In  the  recumbent  position  the  limb  is  flexed  at  an  angle  of 
about  40°,  shortened  the  length  of  the  patella,  but  not  inverted. 
The  trochanter  is  very  prominent,  the  head  of  the  femur  being 
movable  upon  the  dorsum.  The  dislocation  is  dorsal,  but  without 
inversion.  The  knee  cannot  be  depressed  without  raising  the 
loins.  The  patient,  when  erect,  can  bear  about  ten  pounds'  weight 
on  the  limb,  which  can  be  brought  down  by  the  side  of  the  other, 
if  the  pelvis  be  laterally  tilted  to  make  up  for  the  shortening,  and 
thrown  out  behind  to  compensate  the  flexion.  The  buttock  is  flat- 
tened and  widened,  as  in  hip  disease.  The  feet  can  be  everted 
equally,  each  to  an  angle  of  about  45°." 

At  the  close  of  the  above  examination,  the  bone  was  brought 
into  the  socket  by  flexion,  abduction,  and  vertical  extension, 
though  it  easily  slipped  out  of  place.  The  next  day,  as  the 
record  states,  "  the  limb  is  found  to  be  less  flexed,  and  the 
head  of  the  bone  is  in  the  socket.     There  is  still,  however,  a 

1  Massachusetts  General  Hospital,  Surgical  Records,  May,  1868  (vol. 
cxxxiii). 


DORSAL  DISLOCATION.  55 

widening  and  flattening  of  the  nates  on  the  affected  side,  show- 
ing that  the  thigh  is  displaced  laterally,  as  if  the  socket  were 
partially  occluded,  although  engaging  the  head  of  the  femur, 
while  the  knee  is  still  raised  about  four  inches  above  its  fellow, 
the  tensor  vaginae  femoris  being  quite  tense.  The  knee  can 
be  depressed,  but  is  flexed  by  some  elastic  force,  rising  again," 
Under  these  circumstances,  it  was  decided  to  divide  the  last- 
named  muscle  subcutaneously,  near  the  anterior  superior 
spinous  process,  which,  when  done,  allowed  a  considerable 
though  not  complete  extension  of  the  thigh.  The  limb  was 
now  brought  nearly  straight,  and  placed  in  a  Desault's  splint 
until  the  socket  should  be  excavated  by  absorption.  This 
extension  was  continued  until  September  8,  when  the  pa- 
tient began  to  sit  up ;  on  the  13th  he  was  moving  about  on 
crutches,  and  on  the  23d  he  left  the  Hospital,  there  being  no 
lengthening  of  the  leg,  and  only  some  atrophy  of  the  muscles 
of  the  thigh.  That  the  luxation  was  unequivocal  in  this  case 
is  attested  by  the  presence  of  the  head  of  the  bone  upon  the 
dorsum,  —  the  femur  being  flexed,  although  the  foot  was 
straight.  If  the  bones  were  sound,  this  absence  of  inversion 
would  indicate  rupture  of  the  outer  fasciculus  of  the  Y  liga- 
ment. But  the  marked  lateral  displacement,  resulting  from 
the  inability  of  the  bone  fairly  to  enter  its  socket,  even  when 
placed  and  held  there,  implies  some  anomaly,  —  either  the 
callus  of  fracture,  the  remains  of  capsule,  or  the  presence  of 
cicatricial  tissue,  partially  occluding  the  socket. 

A  little  girl  three  and  a  half  years  old  entered  the  Massa- 
chusetts General  Hospital  with  unequivocal  signs  of  dorsal 
dislocation  of  twelve  days'  standing.  I  flexed  and  abducted 
the  limb,  rotating  it  outward,  and  after  some  little  effort,  by 
pressing  the  head  of  the  bone  toward  the  socket,  between  the 
fingers  applied  to  the  superior  spinous  process  and  the  thumb 
upon  the  trochanter,  succeeded  in  reducing  it. 


56  DISLOCATION  BELOW  THE   TENDON. 

DORSAL   BELOW   THE   TENDON. 

It  has  been  before  remarked  that  when  the  flexion  method 
is  universally  adopted  it  will  be  practically  needless  to  classify 
separately  the  dorsal  luxations.  Their  varying  relation  to  the 
small  rotator  muscles  has,  however,  been  already  shown,  and 
the  strength  of  one  of  these  muscles  may  entitle  it  to  separate 
consideration. 

The  dislocation  hitherto  distinguished  as  "  upon  the  ischiatic 
notch,"  and  unnecessarily  associated  with  it,  is  characterized 
by  Sir  Astley  Cooper  as  differing  from  the  dorsal  displacement 
chiefly  in  producing  less  shortening  of  the  limb.  I  believe 
that  no  dislocation  upon  the  ischiatic  notch  is  worthy  of  the 
name ;  that  no  satisfactory  or  practical  result  can  be  based 
upon  this  distinction  alone ;  and  that  it  is  also  an  error  to 
suppose  that  during  reduction  the  femur  ever  notably  "  slips 
into  the  sciatic  notch,"  ^  or  that  the  sciatic  notch  ever  offers 
any  obstacle  to  its  reduction.  A  little  more  or  less  shortening 
and  a  varying  degree  of  inversion  depend  both  on  the  position 
occupied  by  the  head  of  the  femur  upon  the  dorsum  and  on 
the  degree  of  laceration  of  the  capsule.  In  cases  of  this  vari- 
ety which  have  been  recorded  the  signs  were  intrinsically  the 
same,  and  reduction,  if  by  pulleys,  was  usually  effected  in  one 
and  the  same  way,  —  unless  we  seek  an  exception  to  this 
statement  in  a  slight  variation  of  the  angle  of  traction,  quite 
as  likely  to  occur  in  one  case  as  another,  and  even  to  vary 
much  in  different  attempts  upon  the  same  patient. 

But  there  is  one  remarkable  feature  in  some  of  the  recorded 
instances  of  "  ischiatic  "  dislocation.  They  were  erroneously 
supposed  to  have  been  "  irreducible."     Sir  Astley  Cooper  says 

^  See,  for  a  recent  statement  of  this  erroneous  notion,  Holmes's  "  Sur- 
gery" (vol.  ii.  p.  644):  "That  in  our  attempts  to  reduce  a  dislocation 
upward  Ion  the  dorsurn]  the  head  of  the  bone  may  slip  into  the  sciatic 
notch,  there  is  abundant  evidence." 


DISLOCATION  BELOW   THE  TENDON.  57 

"  the  reduction  of  this  dislocation  is  in  general  extremely  dif- 
ficult ;"i  and  this  has  thrown  a  shadow  of  uncertainty  over 
a  large  number  of  other  cases,  where  the  observer,  being  per- 
suaded that  the  reduction  was  more  difiicult  than  usual,  or  the 
limb  less  shortened,  has  taken  it  for  granted  that  the  head  of 
the  bone  was  engaged  in  the  sciatic  notch  and  forcibly  detained 
there,  but  which  were  in  reality  simple  dorsal  dislocations. 

In  view  of  these  facts,  I  propose  to  separate  the  dorsal  dis- 
locations into  two  varieties,  of  some  practical  importance  in 
relation  to  their  reduction.  The  first  has  already  been  con- 
sidered. The  second  includes  only  those  cases  in  which  the 
head  of  the  femur  is  engaged  behind  the  internal  obturator 
tendon  and  the  capsule  lying  beneath  it,  and  which  sometimes 
absolutely  require  the  flexion  method  for  their  reduction. 
This  is  also  a  secondary  dislocation,  in  which  the  bone,  by  a 
movement  of  more  or  less  inversion,  reaches  its  final  position 
behind  the  tendon  after  occupying  one  below  it,  and  is  doubt- 
less of  frequent  occurrence,  as  this  is  the  point  at  which  the 
luxations  below  the  socket  are  first  arrested  in  their  ascent 
upon  the  dorsum.  I  have  ventured  to  call  it,  for  simplicity, 
dorsal  below  the  tendon,  because,  although  the  head  of  the 
femur  lies  behind  the  tendon,  as  it  does  in  dislocation  between 
the  rotators,  it  is  below  it  also,  and  not  above  it,  as  then 
happens  (see  p.  42). 

The  following  are  classical  examples  of  this  accident. 

The  first  is  from  Sir  Astley  Cooper. 

"Case  XLIII.  A  boy  sixteen  years  old  had  a  dislocation  of  the 
thigh  into  the  foramen  ovale ;  he  was  placed  upon  his  sound  side, 
and  an  extension  of  the  superior  part  of  his  thigh  was  made  per- 
pendicularly; the  surgeon  then  pressed  down  the  knee,  but  the 
thigh  being  at  that  moment  advanced,  the  head  of  the  hone  was 
thrown  backward,  and  passed  into  the  ischiatic  notch,  from  which 
situation  it  could  not  be  reduced." 

1  Treatise,  etc.,  p.  73. 


58  DISLOCATION  BELOW   THE   TENDON. 

It  was  probably  this  case  that  led  Sir  Astley  to  enjoin 
"  great  care,"  in  reducing  the  thyroid  luxation,  "  not  to  ad- 
vance the  leg  in  any  considerable  degree,  otherwise  the  head 
of  the  thigh-bone  will  be  forced  behind  the  acetabulum  into 
the  ischiatic  notch,  from  whence  it  cannot  afterward  be  re- 
duced ;  this  accident,"  he  says,  "  I  once  saw  happen."  ^  In 
other  words,  by  flexing  the  thigh  the  Y  ligament  was  relaxed, 
and  the  head  of  the  bone  was  allowed  to  descend  below  the 
socket,^  where  there  was  an  equal  chance  whether,  in  again 
extending  the  limb,  the  head  would  return  inward  to  the  thy- 
roid foramen,  or  slip  outward  upon  the  dorsum  behind  the 
obturator  tendon,  as  actually  happened. 

A  second  is  from  Malgaigne.^ 

A  laborer,  thirty-eight  years  of  age,  had  dislocated  his  hip 
backward.  The  next  day  Lisfranc,  with  eight  assistants, 
endeavored  to  reduce  it  by  straight  extension.  At  the  end 
of  an  hour  their  efforts  were  abandoned,  the  patient  being 
in  a  state  of  collapse.  He  died  on  the  eleventh  day  of  sup- 
purative inflammation  of  the  hip,  resulting  doubtless  from  the 
operation.  At  the  autopsy  the  bone  was  found  to  lie  behind 
obturator  tendon,  and  was  easily  reduced  by  flexion.* 

1  Treatise,  etc.,  p.  63. 

2  This  movement  is  identical  with  that  elsewhere  described  in  connec- 
tion with  the  three  downward  luxations.  A  similar  result  of  relaxing  the 
Y  ligament  by  flexing  the  thigh  occurred  in  a  case  of  Verneuil,  whose 
patient  dislocated  his  hip  a  second  time,  fifteen  days  after  the  original 
accident,  by  suddenly  rising  to  a  sitting  posture.  The  same  thing  hap- 
pened also  to  a  patient  of  Malgaigne  ("  Traite,"  etc.,  p.  840),  and  is  not 
uncommon. 

8  Traite,  etc.,  PI.  XXVI. 

*  For  two  autopsies  of  this  dislocation  see  the  cases  of  M.  Bidard 
(Malgaigne,  "  Traite,"  etc.,  p.  835).  In  both  these  cases,  of  which  the 
second  seems  to  have  been  a  more  complete  luxation  than  the  first,  the 
obturator  internus  was  intact.  In  Queen's  case,  the  sciatic  nerve  was 
engaged  upon  the  neck  of  the  femur  (Medico-Chirurgical  Transactions, 
1868,  vol.  xxxi.  p.  338).  For  a  case  in  which  the  head  of  the  bone  had 
escaped  just  below  the  socket,  and  was  arrested  there  on  its  way  toward 


DISLOCATION  BELOW   THE   TENDON. 


59 


SIGNS. 

The  distinctive  signs  of  this  dislocation,  dorsal  below  the 
tendon,  may  be  thus  stated. 

the  obturator  tendon,  see  Ollivier's  "  Archives  Generales  de  Medecine," 
1823,  torn.  iii.  p.  545 ;  also  Lenoir,  quoted  by  Malgaigne  ("  Traite,"  etc., 
p.  873). 

In  an  interesting  case,  reported  with  its  autopsy  by  Thomas  Wormald 
(London  Medical  Gazette,  1837,  vol.  xix.  p.  657),  the  dislocated  limb  was 
shortened  and  inverted,  forming 
about  half  a  right  angle  with  the 
body,  while  the  shaft  of  the  femur, 
crossing  the  symphysis  pubis,  was 
fixed  immovably  in  this  situation. 
The  head  of  the  femur  had  escaped 
above  the  quadratus,  through  a  rent 
of  the  capsule  opposite  the  upper 
part  of  the  tuber  ischii,  compres- 
sing the  sciatic  nerve,  and  had 
plunged  beneath  the  obturator  ex- 
ternus  muscle  so  as  to  engage  this 
muscle  upon  its  anterior  face.  The 
obtm-ator  internus  was  completely 
ruptured;  the  pyriformis  and  ge- 
melli  were  partially  so ;  also  the 
gluteus  medius  and  minimus  at  their  posterior  edge.  In  this  case  the 
head  of  the  bone,  escaping  between  the  two  muscles,  had  passed  forward 
beneath  the  external  obturator,  instead  of  retreating  backward  behind 
the  tendon  of  the  internal  obturator.  The  luxation  probably  occurred 
when  the  limb  was  flexed  and  extremely  inverted,  to  which  position  may 
also  be  referred  the  rupture  of  the  obturator  internus  muscle.  By  de- 
pressing the  knee  the  head  of  the  bone  would  have  been  carried  upward 
and  backward,  and  the  laceration  so  extended  that  reduction  would  have 
been  easy.  If  the  flexed  knee  had  been  circumducted  outward,  the  exter- 
nal obturator  muscle  would  have  been  partially  ruptured ;  and  this  lesion 
probably  occurs  when  the  head  of  the  bone  is  carried  from  the  dorsum  to 
the  thyroid  foramen,  or  vice  versa.  The  regular  thyroid  luxation,  how- 
ever, occurs  above  this  muscle,  the  upper  edge  of  which  only  need  then 
be  ruptured.  The  external  obturator  and  much  of  the  quadratus  are 
torn  in  the  common  dorsal  dislocation, 

C)  Wormald's  case.  Copied  from  the  London  Medical  Gazette,  1837.  The  head  of 
the  bone,  a,  is  seen  engaged  beneath  e,  the  obturator  externus  muscle ;  /,  sciatic  nerve  j 
b,  obturator  internus;  c,  i,  trochanters;  d,  socket;  h,  gluteus. 


EiG.  10.(«) 


60 


DISLOCATION  BELOW  THE  TENDON. 


The  limb  is  extremely  inverted.     It  crosses  the  opposite 
thigh,  even  as  high  as  the  middle   of  it,  although   in   the 


Fig.  11.1 


Pig.  12  2 


1  Dislocation  below  the  tendon. 
The  inversion  is  here  seen  to  be 
greater  than  in  the  common  dorsal 
luxation,  and  would  be  still  further 
exaggerated  in  the  recumbent  posi- 
tion. 

2  Profile  view  of.  the  same,  show- 
ing the  leg  advanced. 

3  Dislocation  downward  and  out- 
ward toward  the  tuberosity.  This 
may  be  considered  a  first  step  to 
luxation  behind  the  tendon,  which 
it  inclines  to  become  when  the  pa- 
tient is  upright.  The  limb  may  oc- 
cupy any  interval  between  these  two 

luxations,  the  quadratus  muscle  readily  yielding.     (See  Fig.  10.) 


Fig.  13.3 


DISLOCATION  BELOW  THE   TENDON. 


61 


upright  position  it  may  gravitate  to  a  lower  point.  It  is 
considerably  in  advance  of  the  sound  limb.  By  manipulation 
the  capsular  and  muscular  fibres  may  be  so  relaxed  or  torn 
that  this  dislocation  may  be  made  to  resemble  one  higher  up 
on  the  dorsum,  or  be  actually  converted  into  one  by  rupture 
of  the  obturator  muscle. 

THE   MECHANISM   OF   ITS   PEODUCTION,  AND   CAUSE   OP   ITS 
lEREDUCIBILITY. 

In  this  luxation  the  bone  first  escapes  below  the  socket^ 
or  on  its  thyroid  aspect,  when  the  thigh  is  flexed,  as  it  gene- 
rally is.  The  limb 
being  extended  by 
subsequent  vio- 
lence, while  the 
neck  of  the  bone  is 
unyieldingly  sus- 
pended beneath 
the  socket  by  the 
Y  ligament,  the 
head  slips  upward, 
not  only  behind 
the  acetabulum, 
but  also  behind 
the  capsule  and 
the  internal  obtu- 
rator muscle.  The 
fibres  of  the  latter, 
instead    of    lying 

transversely  behind  the  head,  as  when  in  place  (Fig.  14),  now 
lie  obliquely  in  front  of  it,  —  a  tendinous  wall,  interposed  be- 
tween it  and  the  acetabulum  (Fig.  15).^ 


Fig.  14. 


1  A  case  of  dislocation  behind  the  tendon,  with  fracture  of  the  socket, 
exhibited  much  the  same  signs  :  the  right  leg  was  two  inches  shorter  than 


62 


DISLOCATIOX  BELOW  THE   TENDON. 


The  difficulty  of  reducing  this  luxation  by  extension  in  the 
axis  of  the  body  will  be  readily  understood.     In  the  absence 

of   both  posterior 
^x;?*^^-'  capsule    and   inter- 

nal obturator  mus- 
cle, the  head  of  the 
'\      bone     might     be 
ili     slipped    forward 
4/     over  the  lower  mar- 
gin of  the  socket  by 
rotation  outward, 
after    the     pulleys 
liad    sufficiently 
elongated     or     de- 
tached the  Y  liga- 
ment, especially  if 
the     pulleys     were 
"■^^  then    relaxed    and 

/ , .  .  the   thigh  flexed  a 

little.     But  as  the 
obturator    tendon 


Fig.  15.1 


the  left,  the  knee  and  foot  turned  inward.  An  autopsy  showed  the  pos- 
terior part  of  the  acetabulum  broken  off,  and  the  neck  of  the  bone  tightly 
emVjraced  by  the  tendon  of  the  obturator  internus  and  the  gemelli. 
(See  Cooper'.s  "Treatise,"  etc..  Case  LXXI.  p.  113.) 

^  Figs.  14  and  1-5,  —  the  mechanism  of  the  dorsal  dislocation  below 
the  tendon. 

Fig.  14  shows  the  head  of  the  bone  in  it.s  socket,  with  the  obturator 
tendon  in  its  natural  position  behind  it.  The  part  of  the  capsule  which 
lies  beneath  the  tendon  and  behind  the  Y  ligament  has  been  slit,  both  to 
demonstrate  its  thickness  and  to  allow  the  head  of  the  bone  to  rise  as 
high  as  the  ischiatic  notch. 

Fig.  1.5  shows  the  head  of  the  l:)one  dislocated  below  the  tendon  into 
the  neighborhood  of  the  sciatic  notch.  If  the  tendon  were  not  pres- 
ent, the  capsule  would  produce  much  the  same  effect  in  binding  the 
head  of  the  bone  close  upon  the  ilium,  without  the  intei'position  of  the 
muscle. 


DISLOCATION  BELOW   THE   TENDON.  63 

and  its  subjacent  capsule  now  lie  between  the  head  of  the 
bone  and  the  socket,  they  oppose  the  entrance  of  the  head  by 
a  firm  tendinous  wall,  which  is  drawn  down  as  the  head 
descends,  and  which  no  extension  or  rotation,  short  of  its 
ru})ture,  can  displace  or  overcome. 

The  muscle  is  tense,  and  in  its  turn  renders  the  ligament 
more  tense,  carrying  the  head  of  the  bone  backward  and 
upward  toward  the  ischiatic  notch.  The  inversion,  flexion, 
and  adduction  of  the  limb  are  thus  augmented  by  the  com- 
bined and  reciprocal  action  of  the  ligament  and  the  obturator 
muscle,  —  the  latter  being  aided  by  the  subjacent  capsule, 
when  that  remains  untorn.^ 


1  It  has  been  before  said  that  if  the  neck  of  the  femur  be  farther 
driven  upward  so  as  to  rupture  the  obturator  tendon  and  capsule,  the 
luxation  will  become  simply  dorsal.  Malgaigne  correctly  says  that  "the 
ischiatic  luxation  leads  frequently  to  the  iliac  luxation ;  "  but  he  fails  to 
identify  the  mechanism  of  the  change  when  he  asks,  "  May  not  the  for- 
mer also  be  consecutive  to  the  latter,  in  view  of  the  fact  that  by  flexion 
or  strong  traction  the  head  of  the  bone  may  be  drawn  downward  from  the 
dorsum  to  the  notch?"  ("Traite,"etc.,  p.  831.)  In  the  high  dorsal  dislo- 
cation the  small  rotators  would  be  so  lacerated  by  the  ascent  of  the  bone 
or  by  di-awing  it  down  to  reduce  it,  when  engaged  in  their  interstices, 
that  the  luxation  "  on  the  ischiatic  notch  "  would  lose  its  distinctive  fea- 
tures. In  an  interesting  discussion  upon  a  pathological  specimen  of  hip 
luxation  of  five  months'  standing,  where  an  unsuccessful  attempt  had 
been  made  to  reduce  the  bone  by  longitudinal  traction,  M.  Tillaux  main- 
tained that  "  in  backward  luxation  of  the  hip  the  capsule,  and  not  the 
muscles  [notably  the  obturator],  limits  the  movement  of  the  head  of 
the  fenmr."  (Societe  Imperiale  de  Chirurgie,  I'*'"  Juillet,  1808.  L'Union 
Medicale,  No.  79,  p.  57.)  It  is  true  (see  pp.  2,  63)  that  the  obturator 
tendon  and  the  posterior  part  of  the  capsule,  which  is  next  in  strength  to 
the  Y  ligament,  mutually  reinforce  each  other,  so  that  when  the  head  of 
the  bone  rises  behind  the  socket  it  is  generally  engaged  behind  both  these 
fibrous  walls.  But  their  mechanical  action  being  identical,  it  is  unneces- 
sary to  decide  which  under  these  circumstances  would  first  be  ruptured. 
The  capsule  yields  fibre  by  fibre  to  the  ascending  bone,  while  the  com- 
parative elasticity  of  the  tendinous  muscle  preserves  it  (Fig.  1-5),  until 
at  the  moment  of  the  final  rupture  of  the  tendon  the  dislocation  has 
become  practically  iliac,  and  can  now  be  reduced,  though  disadvantage- 


64  DISLOCATION  BELOW  THE   TENDON. 


REDUCTION. 

The  reduction  is  simple.^  The  head  of  the  bone,  having 
reached  its  present  position  by  circumduction  of  the  flexed 
limb  inward,  must  be  reduced  by  circumduction  of  the  ex- 
tended limb  inward.  When  the  thigh  is  raised  perpendicu- 
larly to  the  floor,  the  head  of  the  bone  is  unlocked  and  lies 
below  the  socket,  and  needs  only  to  be  jerked  upward  into  its 
place ;  or  the  suspended  pelvis  may  be  depressed,  or  the  thigh 
abducted  and  rotated  outward,  as  in  the  common  dorsal  dislo- 
cation.2  The  laceration  of  the  capsule  is  probably  already  suf- 
ficient, and  will  not  need  to  be  enlarged.     It  will  be  observed 

ously,  with  pulleys,  by  straight  traction  through  the  slit  thus  made  behind 
the  capsule.  It  may  be  safely  asserted,  first,  that  the  tendon  is  usually 
present  in  these  cases  of  the  iliac  luxation  by  inversion,  unless  the  bone 
has  risen  so  high  iipon  the  dorsum  that  the  posterior  capsule  also  has 
been  ruptured ;  and,  secondly,  that  the  tendon  resists  longest,  and  best 
characterizes  the  luxation. 

1  Mr.  Nunneley,  in  the  paper  before  quoted,  expresses  the  contrary 
belief,  that  in  this  luxation  reduction  by  manipulation  will  be  more  diffi- 
cult, and  will  more  frequently  fail,  than  in  any  other  form  of  dislocation 
to  which  the  hip  is  liable. 

-  M.  Lisfranc  readily  reduced  a  luxation  "  upon  the  sciatic  notch  "  by 
the  method  of  Despres,  twelve  days  after  the  accident.  The  pelvis  being 
fixed,  "  he  adducted  the  limb,  at  the  same  time  flexing  the  thigh  and  leg  ; 
placing  his  fore-arm  under  the  ham,  and  with  his  right  hand  grasping  the 
ankle  in  order  to  use  the  leg  as  a  lever,  he  instantaneoiisly  reduced  the 
luxation  by  extension,  outward  rotation,  and  abduction." 

For  this  case,  which  embraces  the  principles  of  flexion,  abduction,  out- 
ward rotation  of  the  thigh,  and  the  upward  lift,  see  "  Observations  sur 
Luxations,"  etc.,  M.  Malespine,  Archives  Generales  de  Medecine,  Paris, 
1839.  See  also  Bulletin  de  la  Societe  Anatomique,  18-35,  p.  4,  and  1836, 
pp.  45,  169. 

Mr.  Travers  (London  Medical  Gazette,  Nov.  22,  1828)  relates  a  case  of 
dislocation  "upon  the  ischiatic  notch,"  of  six  months'  standing,  which 
was  reduced  by  pulleys,  but  in  which  the  bone  slipped  out  again  while 
the  thigh  was  flexed  in  bed  during  the  night,  —  the  obvious  result  of 
relaxation  of  the  Y  ligament.  In  subsequent  unsuccessful  efforts  at 
reduction,  the  neck  of  the  bone  was  fractured. 


DISLOCATION  BELOW  THE  TENDON.  65 

that  by  the  flexion  method  this  luxation  and  that  upon  the 
dorsum  are  reduced  in  the  same  way,  and  with  equal  facility. 

I  have  had  but  two  opportunities  of  satisfactorily  identify- 
ing this  dislocation  in  the  living  subject.  The  usual  extended 
position  of  the  luxated  limb  so  endangers  the  obturator  that 
its  condition  must  often  be  a  matter  of  uncertainty,  although 
this  luxation  cannot  be  uncommon  compared  with  that  higher 
up  on  the  dorsum. 

In  the  first  case  alluded  to,  which  did  not  occur  in  my  own 
practice,  the  patient  (a  middle-aged  female)  had  fallen  down 
stairs,  and  the  limb  had  thus  been  subjected  to  a  variety  of 
forces.  It  was  flexed,  greatly  inverted,  and  so  advanced  and 
adducted  across  the  middle  of  the  other  thigh  that  I  did  not 
hesitate  to  recognize  it  at  sight  as  a  dislocation  behind  the 
obturator  tendon ;  and  yet  it  is  possible  that  the  bone  may 
have  been  thrust  between  the  rotators.  With  a  view  to  its 
reduction,  the  limb  was  flexed,  and  a  variety  of  movements 
were  communicated  to  it,  during  which  the  bone  slipped  below 
the  socket,  —  a  change  of  position  accompanied  by  a  sharp 
report,  probably  due  to  the  rupture  of  some  fibrous  band,  or 
possibly  the  tendon  of  a  rotator  muscle.^  It  was  afterward 
lifted  into  its  socket. 

The  following  case  admits  of  no  doubt.  While  correcting 
these  sheets,  I  was  called  to  the  Hospital  to  see  a  middle-aged 
man  who  had  three  hours  before  been  struck  upon  the  hip  by 
a  bale  of  hay.  Having  fallen  over  on  his  left  side,  the  bale 
dropped  from  the  story  above,  striking  upon  his  right  femur 
below  the  trochanter  a  little  in  front,  dislocating  it  outward 
and  downward.  He  said  that  two  physicians  had  unsuccess- 
fully tried  for  an  hour,  with  ether,  to  reduce  it.  He  was  in 
pain,  sitting  up  in  bed,  the  luxated  thigh  greatly  inverted,  and 
flexed  so  that  it  crossed  the  sound  limb  near  the  groin.  (See 
Fig.  13.)     After  he  was  etherized  and  laid  flat,  the  dislocated 

1  In  the  dead  subject  the  muscular  fibres  yield  noiselessly. 


66  THYROID  AND   DOWNWARD  DISLOCATIONS. 

thigh,  when  drawn  down,  crossed  the  other  at  the  junction  of 
the  middle  and  lower  third,  but  still  with  great  and  firm  inver- 
sion. This  position  of  the  bone,  in  connection  with  the  facility 
of  its  reduction  and  the  manner  of  the  accident,  indicated  that 
the  head,  suspended  at  the  trochanter  by  the  Y  ligament,  was 
prevented  from  rising  on  the  dorsum  so  as  to  permit  the  de- 
scent of  the  knee,  by  some  obstacle,  which  could  be  no  other 
than  the  obturator  tendon  and  the  subjacent  capsule,  stretched 
across  its  neck ;  also  that  the  luxation  was  secondary,  the 
bone  having  escaped  below  the  socket  before  rising  behind  the 
tendon.  After  etherization,  the  knee  came  down  somewhat, 
as  the  head  rose  behind  the  tendon.  The  hip  was  reduced  by 
flexion,  abduction,  and  eversion,  with  a  slight  upward  jerk,  at 
the  first  effort,  and  in  three  seconds  from  the  moment  the  limb 
was  grasped  for  flexion. 

THYROID   AND    DOWNWARD    DISLOCATIONS. 

1.  Obliquely  inward  and  downward  on  the  thyroid  foramen. 

2.  Obliquely  inward  and  downward  as  far  as  the  perinaeum. 

3.  Vertically  downward  below  the  acetabulum. 

4.  Obliquely  outward  and  downward  as  far  as  the  tuberosity. 

These  dislocations,  if  we  except  that  upon  the  thyroid  fora- 
men, are  comparatively  rare.  In  view  of  the  frequency  of 
accidents  dislocating  the  bone  while  flexed  or  abducted,  this 
rarity  may  be  explained  by  the  readiness  with  which  the 
extreme  downward  luxations  are  converted  into  those  upon 
the  thyroid  foramen  or  the  dorsum. 

THYROID. 

The  bone  escaping  obliquely  downward  and  inward  beneath 
the  socket  by  a  laceration  of  the  inner  side  of  the  capsule, 
where  it  is  thin  and  membranous,  tends  to  follow  the  inclined 


THYROID   AND   DOWNWARD  DISLOCATIONS. 


67 


plane  of  the  pelvis  toward  the  thyroid  foramen,  where  it  finds 
a  lodgement.^ 

SIGNS. 

The  limb  is  unequivocally  flexed  and  abducted,  the  heel 
being  raised  from  the  floor,  and  the  toe  pointing  outward  and 


Fig.  16.2 


Fig.  17. 


forward.  The  trochanters  being  arrested  and  suspended  by 
the  Y  ligament,  while  the  head  of  the  bone  descends  from  the 
socket,  the  thigh  is  flexed  to  an  angle  of  about  35°  and  also 
abducted,  until  the  great  trochanter,  by  swinging  outward, 

1  For  a  case  of  thyroid  dislocation  occurring  in  a  child  six  months  old, 
see  Lancet,  May  16,  1868. 

■2  Thyroid  dislocation,  —  Fig.  16  showing  the  front  view,  Fig.  17  the 
side  view,  and  Fig.  18  the  back  view  of  the  leg.  The  limb  is  seen  advanced, 
abducted,  and  a  little  everted. 


68 


THYROID  AND  DOWNWARD  DISLOCATIONS. 


gets  a  bearing  on  the  acetabulum,  and  the  adductor  muscles 
become  tense.  The  head  of  the  femur  likewise  rests  upon  the 
pelvis  (enabling  the  patient  sometimes  to  walk  tolerably  well), 
and  is  hindered  from  rising  toward  the  pubes,  and  even  from 


Pig.  18. 


Fig.  19.1 


re-entering  the  socket,  by  the  inner  margin  of  the  acetabulum, 
the  falciform  edge  of  the  lacerated  capsule  above,  perhaps,  con- 
tributiner  its  resistance.^ 


1  The  mechanism  of  the  thyi'oid  dislocation,  showing  the  Y  ligament 
suspending  the  trochanters,  while  the  head  of  the  bone  is  lodged  in  the 
thyroid  foramen,  the  trochanter  resting  on  the  acetabulum.  (From  a 
photograph  taken  in  1861.) 

2  In  a  case  of  M.  J.  Ronx,  the  head  of  the  bone  had  passed  the  thyi'oid 
foramen  and  reached  the  ischium ;  the  leg  was  elongated,  slightly  flexed, 
and  inclined  outward.  The  thigh  could  be  flexed,  adducted,  and  abduc- 
ted, but  not  extended.  After  unsuccessful  traction,  the  luxation  was 
reduced  by  flexion.     (Revue  Medico-Chirurgicale,  torn.  iv.  p.  364.) 


THYEOID   AND   DOWNWARD   DISLOCATIONS.  69 

The  internal  obturator  muscle  is  not  necessarily  broken  even 
in  the  complete  dislocation.  That  part  of  the  capsule  which 
is  attached  near  the  ilio-pectineal  eminence  may  assist  the  Y 
ligament  in  suspending  the  limb,  the  thigh  becoming  in  all 
cases  more  flexed  when  forcibly  inverted.  If  the  inner  branch 
of  the  Y  be  ruptured,  the  bone  is  suspended  by  the  great  tro- 
chanter, and  the  eversion  is  diminished.  Although  it  might 
be  supposed  that  the  extended  psoas  and  iliacus  muscles  are 
concerned  in  the  flexion,  yet  after  the  Y  ligament  is  divided 
the  tense  fibres  of  these  muscles  produce  a  less  degree  either 
of  flexion  or  eversion,  and  can  be  broken  by  depressing  the 
knee.  The  long  muscles  of  the  anterior  part  of  the  thigh  also 
become  somewhat  tense,  and  the  head  of  the  bone  tends  to 
escape  toward  the  perinaeum. 

VERTICAL   DOWNWARD   LUXATION. 

Escaping  directly  downward,  the  head  of  the  bone  may 
remain  upon  the  lower  margin  of  the  socket,  —  the  limb  ex- 
hibiting less  eversion  than  in  the  thyroid  dislocation,  but  the 
luxation  being  practically  of  the  same  general  character, 
provided  the  Y  ligament  be  not  ruptured.  In  Gurney's  first 
case  ^  the  eversion  was  slight ;  the  flexion  moderate,  but  if 
carried  beyond  tlie  sitting  posture,  painful ;  the  knee  length- 
ened by  about  an  inch,  standing  and  sitting ;  the  foot  capa- 
ble of  rotation  inward  and  outward;  and  the  limb  able  to 
support  the  weight  of  the  body  in  walking,  the  patient  hav- 
ing walked  two  hundred  yards  on  the  day  of  the  accident  and 
a  mile  six  days  after.  In  a  second  similar  case  the  patient 
could  walk ;  the  foot  could  be  rotated  outward  and  inward 
freely,  but  the  limb  could  not  be  flexed  to  the  sitting  posture ; 
the  head  of  the  bone  was  felt  behind  and  below  the  acetabu- 

1  See  two  interesting  cases  of  dislocation  of  the  thigh  downward,  by 
Edwin  Gurney,  Esq.,  Surgeon,  Camborne,  Cornwall.  Lancet,  1845, 
vol.  iii.  p.  412. 


70 


THYROID  AND   DOWNWARD   DISLOCATIONS. 


Fig.  20.1 


lum.  In  these  cases  the  bone  obviously  had  a  firm  bearing 
below  the  acetabulum,  which  while  it  was  capable  of  support- 
ing the  weight  of  the  body  in 
walking  allowed  rotation  upon 
its  convex  surface.  Flexion  may 
have  been  hindered  by  the  elon- 
gated extensors. 

Hippocrates  probably  refers  to 
a  case  of  this  sort  (and  not,  as 
has  been  supposed,  to  luxation 
on  the  ischiatic  notch)  when  he 
speaks  of  "  the  leg  and  foot  ap- 
pearing pretty  straight,  and  not 
much  inclined  toward  either  side; 
.  .  .  the  sole  of  the  foot  on  its 
own  line,  and  not  inclined  out- 
ward." Of  the  limb  he  says :  "  It  becomes  much  shorter,  and 
the  patient  can  hardly  reach  the  ground  with  the  ball  of  his 
foot,  —  and  not  even  thus,  unless  he  bend  himself  at  the  groins, 
and  also  bend  with  the  other  leg  at  the  ham ;  or,  if  resting 
upon  the  foot,  the  hips  protrude  backward  far  beyond  the  line 
of  the  foot."  With  a  crutch  the  patient  "will  walk  indeed 
more  erect,  but  will  not  be  able  to  reach  the  ground  with  the 
foot ;  or  if  he  wish  to  rest  upon  the  foot,  he  must  take  a 
shorter  staff,  and  will  require  to  bend  the  body  at  the  groins."  ^ 
This  description  indicates  great  flexion  of  the  limb  without 
inversion  or  eversion  ;  and  if  it  applies  to  a  recent  luxation, 
and  not  to  an  old  one  where  the  foot  has  been  straightened  by 
time,  or  unless  we  suppose  the  lesion  here  described  to  be  the 
result  of  old  hip  disease,  —  an  hypothesis  which  can  hardly 

1  Dislocation  downward.  The  bone  has  descended  toward  the  tuber- 
osity, the  flexion  of  the  thigh  being  proportionate  to  the  descent  of  the 
bone. 

"^  Hippocrates,  "  Genuine  Works,"  etc.,  art.  71. 


THYROID  AND   DOWNWARD  DISLOCATIONS. 


71 


be  considered  possible  in  view  of  the  practical  experience  of 
the  writer,  —  these  signs  are  compatible  only  with  dislocation 
beneath  the  socket. 


DISLOCATIONS    NEAR   THE    TUBEROSITY    OR   PERIN^UM.^ 

When  the  thigh  is  thus  strongly  flexed,  it  is  easy  to  imagine 
that  the  head  of  the 
femur,  suspended  by 
the  Y  ligament  be- 
neath the  lower  mar- 
gin of  the  socket, 
pauses  there,  hesitat- 
ing between  the  thy- 
roid and  the  dorsal 
luxations.    It  has  been 

found     at    various  — 

points  in  the  interval  Fig.  2\.^ 

1  For  a  case  of  dislocation  near  the  tuberosity,  see  Cooper's  "  Treatise," 
Case  LXX.  The  limb  was  "  considerably  shortened  and  inverted,"  form- 
ing half  a  right  angle  with  the  body,  —  the  shaft  of  the  femur  crossing 
the  symphysis,  and  being  fixed  there.  At  the  autopsy  the  head  was  found 
on  the  tuberosity ;  the  obturator  internus  was  ruptured,  and  the  ischium 
and  ilio-pubic  symphysis  were  broken,  —  complications  which  would  not, 
however,  necessarily  modify  the  character  of  this  dislocation. 

For  a  case  of  perineal  luxation,  with  autopsy,  see  Transactions  of  the 
London  Pathological  Society,  vol.  x.  p.  211.  The  thigh  was  much  flexed 
and  abducted,  any  attempt  to  adduct  or  depress  it  being  met  by  resist- 
ance and  pain.  The  head  was  felt  in  the  perinseum.  Reduction  was 
effected  by  drawing  the  thigh  vertically  down  from  the  pelvis,  with  lat- 
eral extension  by  a  towel,  aided  by  the  knee  of  the  operator  in  the  groin. 
The  capsular  ligament  was  extensively  detached,  so  that  the  head  of  the 
femur  easily  protruded.  The  "  ilio-femoral  ligament  was  detached  at  its 
outside,  and  partially  separated  from  the  neck  of  the  femur ;  and  a  small 
rent  extended  from  that  point  into  the  capsular  ligament."  Flexion  here 
was  doubtless  due  to  the  remaining  inner  band  of  the  Y  ligament. 

2  Dislocation  downward  and  inward  toward  the  perinseum.  As  in  the 
other  regular  downward  luxations,  the  flexion  is  proportionate  to  the 
descent  of  the  head  of  the  bone. 


72  THYROID   AND   DOWNWARD   DISLOCATIONS. 

between  these  luxations,  and  directed  into  the  one  or  the  other 
in  attempts  to  reduce  it.  In  extreme  flexion  the  head  may 
reach  as  far  as  the  tuberosity  on  one  side  and  the  ascending 
ramus  of  the  ischium,  and  even  the  perinseum,  on  the  other. 
In  short,  in  the  dead  subject  the  ligament  permits  the  head 
of  the  bone  to  descend  until  the  edge  of  its  articular  surface 
sweeps  the  centre  of  the  tuberosity  and  the  ascending  ramus 
of  the  ischium.  When  found  in  these  positions  in  the  living 
subject,  —  so  far  as  may  be  inferred  from  the  reported  cases, 
—  the  ligament  was  not  ruptured.  Such  being  the  position 
of  the  head  of  the  femur  in  the  dislocations  with  extreme 
flexion,  the  knee  would  occupy  the  extremity  of  the  opposite 
spoke  in  an  imaginary  wheel  of  which  the  Y  ligament  should 
be  the  centre.  The  signs  obviously  vary  with  the  position 
of  the  bone,  the  limb  being  always  flexed  ^  in  proportion  to 
the  downward  displacement  of  the  head  of  the  femur  and 
the  length  of  the  ligament,  —  inverted  when  the  femoral 
head  is  directed  to  the  outside  of  the  socket,  and  everted 
when  it  inclines  to  its  inner  aspect.  If  the  head  of  the  bone 
inclines  a  little  to  the  inside,  resting  near  the  groove  of  the 
external  obturator  tendon,  the  limb  is  a  little  abducted,  elon- 
gated, and  rotated  outward,  this  being  a  first  advance  toward 
the  thyroid  foramen.     If  the  head  of  the  bone  rests  a  little 

1  In  some  of  the  reported  cases  of  downward  dislocation  where  the  head 
was  felt  near  the  tuberosity,  it  is  impossible  not  to  recognize  the  fact  that 
the  flexion  of  the  thigh  was  less  than  it  should  have  been  if  the  Y  liga- 
ment was  sound,  —  as  it  was  in  the  case  of  Stanski,  for  example  (see  note, 
p.  73).  Such  a  case  is  that  of  Bouisson,  where  the  head  was  on  a  level 
with  the  tuberosity,  and  the  thigh  is  said  to  have  been  but  slightly  flexed 
(Gazette  Medicale,  1853,  p.  664).  The  ligament  may  have  been  here  rup- 
tured in  whole  or  in  part,  and  if  so  the  dislocation  was  irregular.  On  the 
contrary,  in  a  fatal  case  reported  by  Mr.  Luke  (Medical  Times  and  Ga- 
zette, vol.  xvi.  p.  12),  the  flexion  of  the  leg  is  not  alluded  to,  although  the 
limb  was  lengthened  one  inch  without  inversion  or  eversion,  and  at  the 
autopsy  the  head  of  the  bone  was  found  just  below  the  acetabulum,  and 
the  capsule  was  lacerated  only  heloiv.    If  so,  the  limb  must  have  been  flexed. 


THYROID  AND   DOWNWARD   DISLOCATIONS.  73 

outside  and  behind  the  axis  of  the  acetabulum,  the  rotation  of 
the  limb  inclines  proportionately  inward,  this  being  a  step 
toward  dislocation  behind  the  tendon  (Fig.  13),  into  which 
this  luxation  may  be  easily  converted  by  depressing  the  knee. 
If  the  head  of  the  bone  is  thrust  down  near  the  tuberosity, 
the  limb  is  in  extreme  flexion,  with  perhaps  adduction.  If 
it  is  forced  inward  upon  the  perinseum,  we  naturally  find 
also,  with  extreme  abduction,  the  thigh  standing  out  at  right 
angles  with  the  body  ;  ^  and  as  there  is  no  firm  bearing  for 
the  trochanter  in  the  perinasum,  as  in  the  thyroid  foramen, 
the  toes  may  be  inverted  or  everted.^ 

1  The  following  case  of  perineal  luxation  is  reported  by  WiUard  Parker, 
in  the  New  York  Journal  of  Medicine,  March,  1852,  p.  188.  A  man  was 
standing  beneath  a  canal  boat,  his  legs  apart,  and  received  the  weight  of 
the  falling  boat  upon  his  back.  The  left  leg  and  thigh  were  found  ex- 
tended at  a  right  angle  with  the  body,  and  a  little  inverted ;  while  the 
head  of  the  femur  could  be  felt  in  the  perinseum  behind  the  scrotum. 
Extension  outward  and  downward  carried  the  head  of  the  bone  into  the 
thyroid  foramen,  whence  it  was  reduced  by  carrying  the  femur  across  its 
fellow. 

A  similar  accident  happened  to  Pope's  patient  (Ibid.,  p.  198),  upon 
whom  a  bank  of  earth  fell  while  he  was  standing  under  it  with  his  legs 
widely  spread.  The  thigh  was  found  to  be  at  right  angles  with  the  body, 
inclined  a  little  forward,  the  head  of  the  bone  projecting  beneath  the  skin 
in  the  perinseum.  Reduction  was  effected  by  lateral  extension  applied 
with  pulleys  to  the  upper  part  of  the  thigh,  the  leg  being  used  as  a  lever. 

The  case  of  Amblard  (quoted  by  Malgaigne,  "  Traite,"  etc.,  p.  876) 
was  attended  with  a  good  deal  of  local  pain,  and  with  I'etention  of  urine. 
The  lesion  was  caused  by  a  fall  from  a  cart  upon  the  leg,  which  is  sup- 
posed to  have  been  already  luxated  by  some  twist  before  the  patient 
reached  the  ground.  The  thigh  was  spread  at  a  right  angle  to  the  body, 
with  a  little  outward  rotation.  To  reduce  it,  the  leg  was  drawn  down- 
ward and  outward,  and  the  head  of  the  bone  lifted  outward  with  a  towel. 
The  head  entered  its  socket  by  the  way  of  the  foramen  ovale. 

The  case  of  Amblard  showed  eversion,  while  that  of  Parker  exhibited 
inversion. 

2  The  annexed  woodcut  (Fig.  22)  represents  the  specimen  of  Stanski 
{Bulletin  de  la  Societe  Anatomique,  1837,  p.  296),  and  is  taken  from  Mal- 
gaigne ("  Traite,"  etc.,  PI.  XXVIL,  Figs.  4  and  5),  whose  description  is 
more  complete  than  that  of  Stanski.     It  shows  the  anchylosed  bones  in  a 


74 


THYROID   AND  DOWNWARD   DISLOCATIONS. 


The  obvious  affinity  and  resemblance  between  these  down- 
ward luxations,  of  which  the  thyroid  is  frequent  and  the  others 

luxation  of  long  standing,  occasioned  by  the  falling  of  a  bank  of  earth 
upon  a  man  while  stooping.  Although  the  dislocation  is  classed  as  thyroid 

by  both  these  writers,  the 
great  flexion  of  the  femur 
indicates  that  the  head  of 
the  bone  had  passed  down- 
ward and  inward  near  the 
tuberosity,  while  the  Y 
ligament  remained  en- 
tire,—  "a  mass  of  bony 
stalactites,  which  seem 
to  prolong  the  inferior 
iliac  spine  downward  to 
join  the  internal  face  of 
the  femur,  to  which  they 
adhere  to  the  extent  of 
four  centimetres,  bending 
round  its  anterior  face, 
and  even  behind  it,  to  join 
the  great  trochanter" 
(Malgaigne),  being,  if  we 
may  judge  from  the  fig- 
ure, the  tense  and  anchylosed  Y  ligament,  beautifully  illustrating  this 
form  of  luxation.  (Compare  with  Figs.  19  and  20.)  Or  it  may  have 
been  that  in  this  case  the  external  ligamentary  band  was  broken,  pro- 
ducing greater  eversion  and  more  flexion.  I  have  examined  only 
Malgaigne's  lithograph  of  this  specimen,  in  which  the  origin  of  the  bony 
plate  from  the  inferior  spinous  process  is  so  clearly  given  that,  if  cor- 
rectly represented,  there  can  be  little  doubt  of  its  real  character.  Yet  it 
is  proper  to  say  that  M.  Houel  alludes  to  it  as  a  part  of  the  tendon  of  the 
psoas  muscle  ("  Manuel  d'Anatomie  Pathologique,"  etc.,  par  Ch.  Houel, 
Professeur  Agrege,  etc.,  Paris,  1862,  p.  231). 

See  also  the  case  of  Keate  (London  ^ledical  Gazette,  vol.  x.,  p.  19). 
The  accident  happened  to  a  gentleman,  who  while  riding  fell  into  a  ditch, 
his  horse  falling  upon  him  and  widely  separating  his  legs.  The  limb  was 
three  and  a  half  inches  longer  than  its  fellow,  "  much  flexed,"  with  very 
great  abduction  and  eversion.  The  head  of  the  bone  was  close  to  the 
tuberosity,  and  freely  movable.  It  was  reduced  by  the  way  of  the  fora- 
men ovale,  —  the  route  of  the  luxation,  as  stated  by  the  patient.  This 
case  may  have  been  "  irregular,"  because  the  operator  was  able  to  elon- 


FiG  22. 


THYROID   AND  DOWNWARD   DISLOCATIONS.  75 

rare,  need  not  be  urged.  The  bone  is  suspended  by  the  Y 
ligament,  and  when  the  head  is  displaced  to  one  side  of  the 
socket  the  limb  passes  to  the  other ;  or  if  the  head  is  arrested 
directly  beneath  the  cotyloid  cavity,  the  limb  is  in  simple 
flexion,  —  the  position  of  the  limb  thus  indicating  that  of  the 
head  of  the  bone,  which  can  then  generally  be  felt,  sometimes 
very  distinctly,  as  in  the  perinaeum. 

In  the  downward  dislocations,  if  the  inner  fasciculus  of  the 
Y  ligament  is  ruptured,  the  head  of  the  bone  is  inclined  down- 
ward by  an  inward  rotation  of  the  limb  still  suspended  at  the 
outer  trochanter,  —  the  head  of  the  femur  being  then  com- 
paratively lower  and  the  limb  less  flexed  than  if  the  inner 
fasciculus  were  unbroken.  Such  a  state  of  the  parts  might 
exhibit  the  head  of  the  bone  in  the  neighborhood  of  the 
tuberosity  without  excessive  flexion,  but  the  limb  would  be 
greatly  inverted. 

REDUCTION. 

The  thyroid  dislocation  is  usually  not  difiicult  of  reduction  ; 
but  the  following  methods  will  illustrate  the  variety  of  expe- 
dients to  which  the  surgeon  may  have  recourse,  —  it  being 
remembered  that  the  rent  of  the  capsule,  which  is  here  thin, 
may  be  enlarged  at  discretion  by  circumduction  of  the  flexed 
thigh  inward. 

1.  Rotation.  —  Flex  the  limb  toward  a  perpendicular,  and 
abduct  it  a  little  to  disengage  the  head  of  the  bone ;  then 
rotate  the  thigh  strongly  inward,  adducting  it,  and  carrying 
the  knee  to  the  floor.  The  trochanter  is  then  fixed  by  the  Y 
ligament  and  the  obturator  muscle,  which  serve  as  a  fulcrum. 
While  these  are  wound  up  and  shortened  by  rotation,  the  de- 
scending knee  pries  the  head  upward  and  outward  to  the 
socket.     As  in  reducing  the  secondary  pubic  dislocation,  the 

gate  or  pull  down  the  limb  after  reduction,  —  a  circumstance  which  he 
attributed  to  a  supposed  fracture  of  the  socket. 


76 


THYROID   AND   DOWNWARD   DISLOCATIONS. 


last  half  of  this  manoeuvre  is  an  inward  circumduction  of  the 
flexed  limb  accompanied  with  rotation,  and  is  practically  the 

reverse  of  the  flex- 
ion, abduction,  and 
eversion  by  which 
a  dorsal  disloca- 
tion is  reduced 
from  the  opposite 
side  of  the  socket. 
In  this  manoeuvre 
the  action  of  the 
ligament  may  be 
aided,  if  necessary, 
by  a  towel  passed 
round  the  upper 
part  of  the  thigh, 
to  draw  the  head 
of  the  femur  up- 
ward and  outward. 
Rotation     outward 


Fig.  23.1 


may  be    substituted   for  inward  rotation. ^ 

1  The  surgeon  is  here  represented  in  the  act  of  rotating  and  circum- 
ducting the  flexed  thigh  inward. 

2  In  the  paper  akeady  quoted,  Dr.  Markoe  cites  the  two  following  cases 
of  thyroid  luxation  reduced  by  rotation  :  — 

(Case  8)  Dr.  Buck  here  reduced  the  bone  by  inward  rotation,  after 
two  failures.  In  the  third  and  successful  attempt,  the  thigh  was  brought 
down  from  entire  flexion  to  a  little  below  a  right  angle,  and  again  rotated 
inward,  when  the  head  of  the  bone  slipped  into  its  place. 

(Case  9)  Markoe,  in  imitating  Buck's  method  by  rotation  inward, 
unintentionally  carried  the  head  of  the  bone  round  the  socket  to  the  sci- 
atic notch,  from  which  position  it  was  returned  to  the  foramen  ovale,  and 
reduced  by  rotation  outward,  the  knee  being  at  the  same  time  strongly 
adducted  toward  and  behind  its  feUow. 

These  cases  are  instructive,  as  showing  that  the  head  of  the  bone  is 
directed  toward  the  socket  when  the  Y  ligament  is  wound  upon  the 
shaft  by  rotation,  tvhether  inward  or  outward;    and  they  correspond  to  the 


THYROID   AND  DOWNWARD   DISLOCATIONS. 


2.  Traction.  — Flex  the  limb  toward  the  abdomen,  and  draw 
the  thigh  outward  by  a  towel  passed  round  the  upper  part ; 
or  thrust  it  out- 
ward by  applying 
the  foot  to  the  in- 
side of  the  groin. 1 

3.  Flex  the  thigh 
upward  and  out- 
ward, and  drag  or 
jerk  it  in  that  di- 
rection toward  the 
socket.  (Fig.  25.) 

4.  Lay  the  pa- 
tient on  his  belly  on 
the  edge  of  a  table, 
the  injured  thigh 
hanging,    and    the 

results  of  iny  own  experiments,  made  before  I  had  read  the  report  of  these 
cases.  In  the  first  case,  the  operator  in  finally  placing  the  thigh  a  little 
below  a  right  angle  tightened  the  ligament  and  directed  the  head  upward, 
while  at  the  same  time  a  passage  was  left  for  the  head  of  the  bone  between 
the  trochanter  and  the  socket.  In  the  second,  the  surgeon,  starting  the 
limb  at  right  angles,  relaxed  the  ligament,  engaged  the  head  at  its  lowest 
point  beneath  the  socket,  and  cai'ried  it  by  inward  circumduction  to  the 
ischiatic  notch.  Had  the  thigh  been  now  again  placed  in  a  vertical  position 
it  could  have  been  jerked  up  into  the  socket.  It  was,  however,  returned 
to  the  thyroid  foramen,  and  reduced  by  outward  rotation.  In  these  cases, 
the  head  entered  the  socket  while  the  knee  was  being  depressed  obliquely 
inward.  It  may  be  superfluous  to  say  that  in  Markoe's  case  inward  rota- 
tion would  probably  have  reduced  the  bone  had  the  thigh  been  less  flexed, 
or  the  manipulation  been  aided  by  oblique  or  vertical  traction  with  a 
towel  round  the  thigh  at  its  upper  part. 

1  In  reducing  a  dislocation  of  this  sort,  flexion  with  lateral  traction 
was  successfully  employed  by  M.  Vertu.  (P.  A.  Vertu,  These,  No.  116, 
Archives  Generales  de  Medecine,  1836,  p.  379.) 

2  The  mechanism  of  the  manoeuvre  shown  in  Fig.  23  is  here  seen. 
The  inner  branch  of  the  Y  ligament  being  wound  round  the  neck,  the 
head  must  rise  toward  the  socket  as  the  femur  is  depressed  inward. 


78 


THYROID   AND   DOWNWARD  DISLOCATIONS. 


leg  bent  to  relax  the  flexors ;    then  draw  the  head  of   the 
femur  outward  with  the  aid  of  a  towel. 

5.  Place  him  in  a  sitting 
posture,  with  a  log  or  post 
or  bedpost  between  his 
thighs,  and  pry  the  head 
outward  over  this  fulcrum 
by  means  of  the  shaft  of 
the  femur  as  a  lever. ^ 

6.  Let  him  lie  on  a  table, 
the  limb  flexed  as  usual. 
Then  let  an  assistant,  turn- 
ing his  back  to  the  patient, 
carry  the  flexed  knee  over 
his  own  shoulder,  grasping 
the  foot,  and  endeavoring 
thus  to  lift  the  pelvis,  while 

the  surgeon  draws  the  thigh  outward  by  a  towel  in  the  groin. 
7.  Let   the   surgeon,  facing    the   patient,  place  the  flexed 
limb  upon  his  shoulder,  and  embracing   the  thigh  near  the 
pelvis,  lift  and  direct  the  head  of  the  bone  toward  the  socket.^ 


Fig.  25.-2 


1  In  illustration  of  the  flexion  method,  see  Cooper  ("  Treatise,"  etc., 
Case  XLVI.)  Eight  hours  after  a  thyroid  dislocation,  attempts  were 
made  to  reduce  it  by  traction  in  the  usual  way,  and  were  continued  un- 
successfully until  late  at  night,  when,  the  pulleys  breaking,  further  pro- 
ceedings were  deferred  until  the  next  day.  The  patient,  having  then 
taken  two  doses  of  tartar  emetic,  was  carried  into  the  operating  the- 
atre at  2  p.  M.  Attempts  at  reduction  were  again  made,  and  powerful 
extension  employed  for  upward  of  an  hour  without  success.  The 
tartar  emetic  was  rei>eated  in  large  doses,  and  the  man,  becoming  faint, 
was  placed  in  a  sitting  posture.  Extension  was  then  made,  and  after 
a  short  time  the  head  of  the  bone  slipj^ed  into  the  acetabulum. 

2  Thyroid  dislocation.  Reduction  by  traction.  The  limb  is  flexed, 
abducted,  and  everted,  relaxing  completely  the  Y  ligament.  (From  a 
photograph  taken  in  1861.) 

3  Method  of  Larrey.     (See  Malgaigue's  "  Traite,"  etc.,  pp.  853-855.) 


THYROID   AND   DOWNWARD  DISLOCATIONS.  79 

8.  Let  the  capsular  orifice  be  enlarged  by  a  little  circum- 
duction of  the  flexed  thigh  inward,  as  if  to  convert  the  thyroid 
into  a  dorsal  luxation ;  and  let  the  pelvis,  suspended  by  the 
limb,  be  then  depressed  by  the  foot  of  the  surgeon,  while  the 
thigh  is  drawn  outward,  if  necessary,  with  a  towel. 

9.  Convert  the  thyroid  into  a  dorsal  luxation,  and  proceed 
accordingly. 

10.  Most  of  these  manoeuvres  may  be  executed  while  the 
patient  lies  on  his  sound  side,  if  counter-extension  be  applied 
as  a  substitute  for  the  weight  of  the  body. 

To  reduce  the  other  varieties  of  downward  luxation,  the 
femur  should  be  flexed  and  its  head  drawn  and  guided  toward 
the  socket,  —  during  which  manoeuvre  these  dislocations  are 
sometimes  converted  into  that  upon  the  thyroid  foramen,  or 
upon  the  dorsum  below  the  tendon. 

For  the  dislocation  downward  we  may  employ  vertical  trac- 
tion, rotating  the  femur  a  little  inward  to  disengage  the  head; 
for  the  dislocation  downward  and  outward,  traction  upward 
and  inward,  with  abduction  and  rotation  outward  if  required 
to  tilt  the  head ;  for  the  dislocation  downward  and  inward, 
traction  upward  and  outward.  In  these  three  injuries  the 
femur  is  of  course  to  be  kept  flexed,  its  head  drawn  and  guided 
toward  the  socket  by  local  pressure,  or  lifted  with  a  towel  if 
necessary,  with  rotation  outward,  and  abduction  when  the 
bone  is  directly  below  or  outside  the  socket,  and  with  circum- 
duction at  discretion  when  required  to  enlarge  the  capsular 
opening. 

See  also  the  methods,  6,  7,  and  8. 


80 


DISLOCATION  ON  THE  PUBES. 


DISLOCATION  UPON  THE  PUBES,  AND  BELOW  THE 
ANTERIOR  INFERIOR  SPINE  OF  TEE  ILIUM.  (Sub- 
spinous.) 

dislocation  upon  the  pubes. 

In  this  dislocation  the  head  of  the  bone  is  felt  upon  the 
pubes ;  the  limb  is  a  little  shortened  and  everted,  abducted 


Fig.  26.1 


Fig.  27.2 


and  advanced.     A  laceration  of  the  inner  aspect  of  the  cap- 
sule allows  the  bone  to  escape  obliquely  upward,  to  a  point 

1  Pubic  dislocation.     The  foot  is  everted,  the  thigh  advanced  and 
abducted. 

2  Pubic  dislocation.     The  head  of  the  bone  is  seen  in  the  groin,  sus- 
pended by  the  Y  ligament.     (From  a  photograph  taken  in  1861.) 


DISLOCATION  ON   THE  PUBES.  81 

upon  the  pubes  distant  in  proportion  to  the  violence  of  the 
force  displacing  it.^ 

Complete  pubic  dislocation  is  impossible  unless  the  capsule 
beneath  the  obturator  internus  is  ruptured,^  after  which  this 
muscle  everts  the  limb  until  the  trochanter  bears  upon  the 
pelvis.  If  this  muscle  is  ruptured,  the  psoas  and  iliacus,  bind- 
ing the  neck  of  the  bone  to  the  pubes,  may  produce  a  degree 
of  eversion ;  but  the  principal  agent  of  eversion  even  then  is 
the  Y  ligament,  which  also  embraces  the  neck.  The  untorn 
capsular  fibres  and  tlie  obturator  muscle  are  agents  in  prevent- 
ing flexion,  their  insertions  being  lower  than  the  head  of  the 
displaced  bone,  which  then  becomes  a  fulcrum,  the  lever  in 
flexion  being  the  shaft ;  but  in  pubic  dislocation  nearer  to  the 
iliac  spine,  the  obturator  is  not  tense,  and  flexion  is  then  prob- 
ably hindered  by  the  outer  and  inferior  parts  of  the  capsule, 
when  they  still  exist.  Both  the  muscle  and  the  capsule  act  in 
preventing  inversion.  Dislocation  to  the  neighborhood  of  the 
symphysis  implies  a  rupture  of  the  inner  branch  of  the  Y 
ligament.^ 

^  Larrey  is  said  to  have  seen  a  case  of  pubic  dislocation  in  which  the 
femm-  was  flexed  at  nearly  a  right  angle  with  the  body.  (Hamilton, 
"  Practical  Treatise,"  etc.,  p.  655.)  It  is  fair  to  suppose  that  it  could  have 
been  brought  down  to  the  usual  position. 

2  In  an  autopsy  of  a  case  of  pubic  dislocation,  recorded  in  a  paper 
by  Mr.  Bransby  Cooper  (Guy's  Hospital  Reports,  1836,  vol.  i.,  p.  82),  the 
gemini  and  quadratus  femoris  had  suffered  from  laceration  and  subse- 
quent ulceration,  implicating  all  the  outward  rotators  of  the  thigh. 

^  A  careful  autopsy  of  pubic  luxation  is  recorded  in  a  communication 
of  M.  Aubry,  read  by  M.  Maisonneuve,  to  the  Societe  de  Chirurgie  (Ar- 
chives Generales  de  Medecine,  Paris,  1853,  p.  35.5).  The  head  of  the  bone 
projected  in  the  groin ;  the  limb  was  rotated  outward  with  flexion,  a  little 
abduction,  and  shortening  to  the  extent  of  one  quarter  of  an  inch.  The 
autopsy  showed  the  psoas  and  the  crural  nerve  upon  the  anterior  surface 
of  the  neck.  Half  the  anterior  circumference  of  the  capsule  was  torn  at 
a  quarter  of  an  inch  from  its  cotyloid  insertion,  the  neck  of  the  femur 
being  held  in  a  sort  of  button-hole  between  its  fibrous  edge  and  the  co- 
tyloid rim.  Flexion  of  the  thigh  obvioiisly  relaxed  this  fibrous  band, 
liberating  the  neck ;  extension  produced  the  contrary  effect,  strangulat- 

6 


82 


DISLOCATION  ON  THE  PUBES. 


DISLOCATION   BELOW   THE    ANTERIOR   INFERIOR   SPINE   OF   THE 
ILIUM,   OR   SUB-SPINOUS. 

The  head  of  the  bone  ranges  along  the  pubes,  displaced  ac- 
cording to  the  violence  and  direction  of  the  injury.     If  thrust 


Fig.  28.1 


Fro.  29.2 


directly  upward,  the  bone  may  lie  beneath  the  Y  ligament  and 
the  inferior  iliac  spine ;  but  this  displacement  requires  that 

ing  the  neck.     Of  the  muscles,  the  external  obturator  was  relaxed ;  the 
pp'iformis,  internal  obturator,  and  gemelli  appeared  elongated. 

1  Pubic  dislocation  nearer  the  spine.  The  limb  is  here  seen  everted, 
but  is  usually  a  little  more  advanced  and  abducted.  Nelaton,  however, 
describes  a  similar  absence  of  flexion  ("  Clinical  Lectures  on  Surgery  by 
M.  Nelaton."  from  Notes  taken  by  W.  F.  Atlee,  M.D.,  Phila.,  1855,  p.  213). 

2  Sub-spinous  dislocation.  The  neck  of  the  bone  is  seen  lying  beneath 
the  Y  ligament,  which  is  tightly  stretched  across  it.  (From  a  photograph 
taken  in  1861.) 


DISLOCATION  ON  THE   PUBES. 


83 


the  upper  part  of  the  capsule  should  be  completely  detached 
from  the  edge  of  the  socket.  The  firm  bearing  of  the  neck 
against  the  Y  ligament  may  then  explain  how  the  patient  has 
in  some  recorded  cases  been  able  to  walk  immediately  after 
this  accident.^  The  limb  is  still  everted,  but  less  abducted  or 
advanced,  and  the  head  of  the  bone  is  plainly  felt  in  its  new 
position,  —  in  the  absence  of 
which  evidence  the  shortening 
and  eversion  might  possibly 
be  mistaken  for  fracture  of 
the  neck.2 

When  the  bone  has  been 
thus  displaced,  the  psoas  and 
iliacus  tendon  is  sometimes 
thrown  off  the  neck  of  the 
femur  toward  the  pubes  where 
it  then  lies  slack.  But  even 
when  in  place,  the  action  of 
this  tendon  is  wholly  secon- 
dary to  that  of  the  Y  ligament 
in  producing  either  flexion  or 
eversion,  as  may  be  shown  by 
its  division,  after  which  the 
position  of  the  dislocated  bone  Fig.  so.^ 


1  See  Malgaigne's  "  Traite',"  etc  ,  pp.  844,  845. 

2  The  above  figure  (Fig.  30)  from  Malgaigne  ("Traite,"  etc.,  PI. 
XXVII.  Fig.  1)  represents  a  specimen  elaborately  described  by  M.  Gely 
(Bulletin  de  la  Societe  Anatomique,  1840,  p.  303).  The  accident  oc- 
curred to  an  insane  person,  a  long  time  before  death.  The  neck  of  the 
bone  rides  upon  the  inferior  spine,  and  the  leg  is  much  everted.  This 
eversion  may  perhaps  be  referred  to  pathological  changes,  but  may  have 
occurred  at  the  time  of  the  accident.  Gely  rightly  supposes  the  weight 
of  the  body  to  have  been  supported  by  the  upper  part  of  the  capsule, 
reinforced  by  the  tendon  of  the  rectus  muscle  (Bulletin,  pp.  320,  327). 

8  Sub-spinous  dislocation. 


84  DISLOCATION  ON  THE  PUBES. 

remains  unchanged ;  while  if  the  Y  ligament  be  divided 
without  the  tendon,  the  bone  drops  to  a  position  near  the 
thyroid  foramen,  with  little  flexion,  —  an  attitude  of  the  limb 
resembling  the  irregular  dislocation  toward  the  perinaeum  or 
on  the  tuberosity.! 

REDUCTION. 

I  have  never  met  with  pubic  dislocation  in  the  living  sub- 
ject, and  am  therefore  unable  to  speak  of  the  extent  of  a 
difficulty  in  flexion  alluded  to  by  some  writers  as  character- 
istic of  this  luxation.  But  there  is  ample  evidence  that  this 
difdculty  is  neither  insuperable  nor  constant.  The  pubic 
dislocation  has  often  been  reduced  by  flexing  the  limb ;  and 
if  the  obturator  tendon  and  its  subjacent  capsule  resist  flex- 
ion in  the  living  as  in  the  dead  subject,  the  limb  needs  only 
to  be  drawn  down  toward  the  socket  while  in  the  act  of 
being  flexed. 

If  the  bone  has  been  thrust  upward  between  the  Y  ligament 
and  the  pubo-femoral  band,  and  the  capsular  orifice  be  small, 
this  band  may  be  ruptured  by  circumduction  or  even  rotation 
of  the  flexed  thigh  inward.  But  well-marked  pubic  disloca- 
tion usually  implies  a  rupture  of  the  capsule  which  extends  to 
its  inner  and  lower  aspects.     (See  p.  81.) 

It  is  difficult  to  reduce  the  pubic  dislocation  by  straight 
extension,  and  various  accidents  have  happened  in  attempt- 
ing it. 

1  If  the  head  of  the  bone  be  still  further  displaced  outward,  it  lies 
beneath  the  inferior  spinous  process,  as  in  the  case  of  Wormald  (London 
Medical  Gazette,  January,  1837,  p.  164),  where  the  limb  being  somewhat 
everted,  abducted  a  little,  and  shortened  half  an  inch,  the  new  cavity 
was  formed  in  part  by  the  upper  portion  of  the  cotyloid  ligament.  The 
patient,  who  died  twenty-six  years  after  the  accident,  was  said  to  be 
able  to  walk  well,  being  "  engaged  in  carrying  out  beer  for  a  publican 
in  Portugal  Street,"  —  a  statement  which  Malgaigne  oddly  translates, 
*'■  pour  porter  un  mort  au  cimetiere"  ("  Traite,"  etc.,  p.  871). 


DISLOCATION  ON   THE   PUBES.  85 

The  reduction  may  be  accomplished  in  a  variety  of  ways, 
among  which  are  the  following,  combining  angular  traction 
and  rotation. 

1.  By  Traction  and  Rotation. — Flex  the  limb  to  a  right 
angle,  while  drawing  it  down ;  rotate  either  inward  or  out- 
ward, and  directing  the  head  of  the  bone  by  its  shaft,  rock 
it  downward  into  its  place.^ 

1  Two  cases  of  pubic  dislocation  skilfully  reduced  by  manipulation  are 
reported  by  Dr.  E.  J.  Fountain,  of  Davenport,  Iowa,  in  the  New  York 
Journal  of  Medicine,  etc.,  January,  1856,  p.  69.  In  the  first  case,  the 
patient  was  laid  upon  the  floor  on  a  quilt,  made  insensible  with  chloro- 
form, and  the  limb  was  rotated  outward.  The  leg  was  then  flexed  and 
carried  across  the  opposite  knee  and  thigh,  the  heel  kept  well  up  and  the 
knee  pressed  down.  This  motion  was  continued  by  carrying  the  thigh 
over  the  sound  one  as  high  as  the  upper  part  of  the  middle  third,  the  foot 
being  kept  firmly  elevated ;  then  the  limb  was  carried  directly  upward 
by  raising  the  knee,  which  was  gently  oscillated,  when  the  head  of  the 
bone  dropped  into  its  socket.  The  time  of  this  operation  was  from 
twenty  to  thirty  seconds,  and  the  force  slight.  In  a  second  case,  rota- 
tion and  fiexion  produced  greater  pain,  and  the  limb  was  less  movable. 
Here  also  the  knee  and  foot  were  rotated  outward,  the  leg  then  fiexed 
across  the  sound  thigh,  the  heel  kept  up  and  the  knee  pressed  down. 
The  whole  was  carried  in  this  position  across  the  sound  thigh  directly 
upward  to  the  flexed  position,  the  operator  holding  the  foot  firmly  up 
and  making  oscillations  with  the  knee,  when  the  head  of  the  bone  slipped 
into  the  socket.  About  twenty  seconds  sufiiced  for  the  operation,  which 
was  performed  without  the  use  of  chloroform. 

It  wdll  be  observed  in  these  cases  that  no  real  difficulty  was  encoun- 
tered in  flexion.  The  limb  was  flexed,  and  the  vertical  femur,  rotated 
outward,  was  rocked  down  into  its  place.  The  outward  rotation  of  the 
flexed  femur  made  the  outer  branch  of  the  Y  ligament  tense,  with  an 
interval  through  wdiich  the  head  of  the  bone,  already  rotated  to  a  point 
just  above  the  socket,  descended  into  it.  Perhaps,  as  Dr.  Fountain  recom- 
mends, the  whole  manoeuvre  should  be  commenced  with  an  outward 
rotation,  to  be  maintained  till  the  reduction  is  accomplished;  but  it 
seems  to  me  that  this  rotation  is  unnecessary  until  after  the  limb  is 
flexed. 

Devilliers  and  Aubry  each  reduced  a  pubic  dislocation  by  flexion  and 
rotation  inward  instead  of  outward,  and  Larrey  by  simple  downward 
pressure  at  the  groin,  with  the  knee  over  his  shoulder  (Malgaigne, 
"  Traite,"  etc.,  pp.  853,  854). 


86 


DISLOCATION   ON  THE   PUBES. 


Fig.  31.1 


2.   While  extending  the  limb   horizontally,  with  counter- 
extension  by  the  foot  in  the  peringeum,  raise  the  patient  to 

a  sitting  posture,  coun- 
ter-extend against  the 
pubes,  and  rotate  in- 
ward. 

3.  The  same  method 
may  be  pursued,  the 
patient  lying  on  his 
belly  on  the  edge  of  a 
table,  or  on  his  sound 
side. 


4.  See  Reduction  of 
the  Thyroid  Dislocation, 
Nos.  7  and  8. 

5.  Flex  and  abduct 
the   limb   and   draw  it 

outward,  at  the  same  time  pressing  the  head  downward  and 
outward. 

By  Rotation.  —  Reduction  by  rotation  is  to  be  accomplished 
by  much  the  same  method  as  in  the  thyroid  dislocation,  ex- 
cept that  in  the  pubic  luxation  the  flexed  limb  should  be 
carried  across  the  sound  thigh  at  a  higher  point.  First, 
semi-flex  the  thigh  to  relax  the  Y  ligament,  at  the  same  time 
drawing  the  head  of  the  bone  down  from  the  pubes.  Then 
semi-abduct  and  rotate  inward,  to  disengage  the  bone  com- 
pletely. Lastly,  while  rotating  inward  and  still  drawing 
on  the  thigh,  carry  the  knee  inward  and  downward  to  its 
place  by  the  side  of  its  fellow.  As  in  the  thyroid  luxation, 
this  manoeuvre  guides  the  head  of  the  bone  to  its  socket  by 

1  Pubic  dislocation.  Reduction  by  traction.  The  limb  has  been  here 
flexed  and  abducted,  for  reduction  by  traction  and  local  pressure.  The 
abduction  is  rej)resented  as  greater  than  necessary.  (From  a  photograph 
taken  in  1861.) 


ANTERIOR   OBLIQUE  DISLOCATION.  87 

a  rotation  wliich  winds  up  and  shortens  the  ligament,  enabling 
the  operator,  by  depressing  the  knee,  to  pry  the  head  of  the 
bone  into  its  place. 

Brieiiy,  while  drawing  upon  the  thigh,  flex  and  abduct  it  to 
disengage  the  head  ;  then  rotate  inward,  and  when  the  bone 
leaves  the  pubes,  continue  the  rotation  while  straightening 
the  limb  ;  or  circumduct  the  bent  limb  inward.^ 

Aid  these  manoeuvi-es  by  drawing  the  flexed  groin  outward 
with  a  towel,  or  otherwise  depressing  it.^ 

If  by  these  combined  movements  of  traction,  leverage,  and 
rotation  —  of  which  the  Y  ligament  and  the  obturator  tendon, 
when  it  is  unbroken,  are  the  centre  —  the  luxation  is  not  re- 
duced, it  will  perhaps  be  converted  into  one  near  the  thyroid 
foramen,  the  rules  for  the  reduction  of  which  will  then  apply 
here.^ 

ANTERIOR    OBLIQUE    DISLOCATION. 

The  remaining  luxations  imply  a  free  laceration  of  the 
tissues  about  the  joint,  and  sometimes  of  a  part  of  the  Y 
ligament  itself. 

1  See  case  of  Dr.  J.  M.  Iivme  (British- American  Journal,  March,  1861, 
p.  282).  A  complete  pubic  dislocation  of  the  right  hip  was  reduced  by 
flexing  the  thigh  wpon  the  pelvis,  carrying  the  knee  over  the  umbilicus 
to  the  left  side  of  the  body,  and  thence  to  a  state  of  extension,  when  the 
head  slipped  in. 

2  Baron  Larrey  has  reported  a  case  of  dislocation  in  front  of  the  hori- 
zontal portion  of  the  pubes,  which  he  reduced  by  suddenly  raising  with 
liis  shoulder  the  lower  extremity  of  the  femur,  while  with  both  hands  he 
pressed  the  head  of  the  bone  downward.  (Hamilton,  "  Practical  Treat- 
ise," etc.,  p.  657,  and  London  Medico-Chirurgical  Review,  December, 
1820,  p.  500). 

3  Mr,  Annandale,  after  some  unsuccessful  manipulation,  succeeded 
by  flexion  in  reducing  a  pubic  dislocation  of  three  days'  standing, 
but  used  pulleys  to  withdraw  the  head  of  the  bone  from  the  pubes  by 
outward  extension.  (Thomas  Annandale,  F.  R.  S.  E.,  etc..  Assistant 
Surgeon  of  the  Royal  Infirmary ;  Edinburgh  Medical  Journal,  1867, 
p.  997.) 


88 


ANTERIOR   OBLIQUE   DISLOCATION. 


In  a  common  dorsal  dislocation,  let  the  leg  be  carried  across 
the  symphysis,  so  that  the  outer  and  convex  surface  of  the 


Fig.  33.2 

1  Figs.  32,  33,  34,  —  anterior  oblique  dislocation.  The  limb  is  here 
extremely  everted,  crossing  the  other  above  the  knee.  The  general  ana- 
tomical character  of  the  luxation  is  seen  in  Fig.  33,  vi^here  the  Y  ligament 
is  still  entire,  the  limb  crossing  the  other  high  uji.  As  the  limb  descends 
toward  a  perjiendicular  the  outer  fibres  of  the  ligament  yield,  until,  as  it 
reaches  the  position  seen  in  Fig.  37,  only  the  inner  fasciculus  remains. 
The  head  of  the  bone  is  then  hooked  over  this  inner  fasciculus,  as  seen  in 
the  dotted  line  (Fig.  37),  and  the  supra-spinous  luxation  is  complete.  If 
now  thrust  back  upon  the  dorsum,  the  dislocation  is  simply  the  everted  dor- 
sal, as  shown  in  Fig.  40,  where,  however,  the  toes  may  be  inverted  at  will. 

2  Anterior  oblique  luxation.  By  depressing  the  shaft  of  the  femur 
the  head  rises  over  the  inferior  spinous  process,  as  the  external  part  of 
the  ligament  yields. 


ANTERIOR  OBLIQUE  DISLOCATION. 


89 


socket  shall  correspond  to  the  hollow  beneath  the  neck  of  the 
femur.  With  some  force  the  thigh  can  now  be  everted,  and 
afterward  brought  down  across  the  upper  part  of  its  fellow. 
It  is  here  firmly  locked,  with  great  shortening  and  some  ever- 
sion,  the  limb  facing  forward  and  obliquely  crossing  the  oppo- 
site thigh,  while  the  toe  points  outward,  —  a  position  not 
wholly  ungraceful,  and  suggesting  some  attitudes  in  dancing. 
(Figs.  32  and  33.)  i 

If  in  this  position  it  is  desired  to  bring  the  limb  toward  a 
perpendicular,  the  outer  branch  of  the  Y  ligament  must  be 
ruptured.  Thus  liberated,  it  hangs  suspended  by  the  inner 
ligament,  and  becomes  capable  of  lateral  motion  and  of  rota- 
tion ;  and  this  is  probably  the  condition  under  which  supra- 
spinous luxation,  although  rare,  usually  occurs.     (Fig.  35.) 

The  anterior  oblique  dislocation  may  be  reduced  by  inward 
circumduction  of  the  extended  limb  across  the  symphysis,  with 
a  little  eversion,  if  necessary,  to  disengage  the  head  of  the 


1  For  a  description  of  the 
annexed  woodcut,  taken  from 
Cooper,  and  which  exhibits  the 
position  of  the  anterior  oblique 
luxation,  see  case  of  Oldknow 
(Guy's  Hospital  Reports,  No.  1, 
p.  97),  also  Cooper  ("  Treatise,' 
etc.,  Case  LXVII.).  The  foot 
is  said  to  have  been  very  much 
everted,  only  the  toes  touching 
the  gi'ound.  But  the  patient 
had  lived  twelve  years  after  the 
accident,  and  something  may 
be  ,  allowed  for  pathological 
changes.  For  a  larger  figure 
representing  this  dislocation,  see 
a  paper  of  Bransby  Cooper, 
Guy's  Hospital  Reports,  1836, 
vol.  i.  p.  81. 


Fig.  34.(«) 


(«)  Anterior  oblique  luxation. 


90 


SUPKA-SPINOUS  DISLOCATION, 


bone.     Inward  rotation  then  converts  this  into  the  common 
luxation  upon  the  dorsum. 


Fig.  35.1 


DISLOCATIONS  IN   WHICH  THE   OUTER  BRANCH 
OF   THE   Y  LIGAMENT   IS   BROKEN. 

SUPRA-SPINOUS   DISLOCATION.^ 

The  head  of  the  bone  has  been  found  above  the  inferior 
spinous  process,  the  neck  lying  across  the  edge  of  the  pelvis, 
the  trochanter  turned  back,  and  —  d.6  is  said  —  not  readily 
'discovered.     The  limb  was  shortened  two  or  three  inches,  a 

1  This  figure  is  intended  to  show  in  diagram  the  external  portion  of 
the  Y  ligament  detached,  as  in  the  supra-spinoiis  and  everted  dorsal 
luxations. 

'^  See  case  of  Cummins  (Guy's  Hospital  Reports,  vol.  iii.).  Cooper 
("  Treatise,"  etc..  Case  LXV.)  cites  this  case  as  anomalous,  illustrating 
it  with  a  figure  which  represents  the  head  of  the  bone  as  projecting 
farther  upon  the  abdomen  than  the  context  indicates.  The  leg  was 
shortened  three  inches,  and  could  not  be  drawn  down.     The  limb,  which 


SUPRA-SPINOUS   DISLOCATION. 


91 


little  abducted,  and  everted,  —  this  eversion  being  sometimes 
so  great  that  the  toes  pointed  backward,  although  in  one  of 

was  much  everted,  could  not  be  rotated  inward.  Cooper  considers  this 
to  be  "  a  variety  of  dislocation  hitherto  unknown." 

Travers  (Medico-Chirurgical  Transactions,  vol.  xx.  p.  113)  thus  de- 
scribes a  case  :  "  The  trochanter  is  felt  below  and  to  the  outer  side  of  the 
anterior  superior  spinous,  process  of  the  ilium.  The  neck  of  the  bone 
lies  apparently  between  the  two  anterior  spinous  processes,  so  that  when 
the  patient  is  erect  the  limb  seems  as  it  were  slung  or  suspended  from 
this  point." 

Sir  Astley  Cooper  ("  Treatise,"  etc..  Case  LXII.)  cites  a  case  of  old 
dislocation  "  on  the  pubes."  An 
accurate  account  of  the  autopsy, 
with  the  annexed  figm-e,  is  given 
by  N.  Cadge,  F.  R.  C.  S.,  Xorwich 
(Medico-Chirurgical  Transactions, 
vol.  xxxviii.  p.  88).  The  left  leg 
was  full  an  inch  and  a  half  shorter 
than  the  right;  the  toes  were 
turned  outward ;  and  while  the 
body  lay  on  its  back  the  foot 
rested  completely  on  the  outer 
border.  A  large,  globular,  bony 
tumor  was  felt  in  the  groin,  close 
to  the  superior  spine  of  the  ilium. 
On  dissection,  the  head  of  the 
femur  was  found  in  the  interval 
between  the  anterior  superior  and 
anterior  inferior  spinous  processes 
of  the  ilium.  The  head  of  the  fe- 
mur was  covered  with  a  complete 
bony  cap,  lined  with  a  dense,  pearly- 
white  tissue,  resembling  fibro-carti- 
lage  (Fig.  36).     The  edge  of  the 

new  cavity  was  connected  with  the  neck  of  the  thigh-bone  by  a  thick 
capsular  ligament.  The  rectus  muscle,  which  had  been  torn  from 
its  origin,  was  inserted  into  the  edge  of  the  new  cavity,  —  a  condition 
that  suggests  the  ascent  of  the  bone  above  the  inferior  spinous  process 
of  the  ilium  at  the  time  of  the  injury,  with  rupture  of  the  Y  ligament. 
This  luxation  may  have  been  supra-spinous  or  irregular. 

(«•  Supra-spinous  dislocation,     r^,  bony  cap;  &,  fractured  margin  of  ditto ;  c,  socket; 
d,  superior  spinous  process  of  ilium. 


Fio.  .36  "" 


92 


SUrPtA-SPINOUS   DISLOCATION. 


the  cases  related  by  Cooper  they  could  be  brought  forward 
again  to  the  side  of  the  other  foot.  Another  important  fea- 
ture was  that  the  shortened  limb  could  not  be  drawn  down. 

In  this  luxation  the  neck  was  doubtless  hooked  over  the  Y, 
and  perhaps  over  the  tendon  of  the  rectus  muscle  also;  so 
that  direct  extension,  short  of  the  rupture  of  this  ligament, 
was  worse  than  useless.  The  head  of  the  bone  had  been 
thrust  above  and  outside  the  Y  ligament,  upon  which  in  its 
return  the  neck  of  the  femur  had  engaged  itself,  the  main 


Fig.  37.1 


Fig.  38. 


branch  of  the  Y  then  lying  behind  the  neck,  and  so  wound 
around  it  as  to  produce  great  shortening. 

In  the  supra-spinoiis  luxations  cversion  is  due  to  the  inter- 
nal obturator,  when  it  remains  entire,  but  also  to  the  tense 
ligament. 


1  Figs.  37  and  38,  —  suiira-spinous  dislocation.     (See  note,  p.  SS.) 


SUPRA-SPINOUS   DISLOCATION. 


93 


The  muscles  inserted  into  the  back  of  the  trochanter,  es- 
pecially the  obturator  internus,  hinder  the  head  of  the  bone 
from  advancing  upon  the  spinous  process ;  but  when  they 
are  divided,  the  head  advances  toward  the  abdomen.  The 
first  degree  of  supra-spinous  luxation,  which  is  represented 
in  the  woodcut  (Fig.  37), 
requires  the  rupture  of 
only  the  outer  fibres  of 
the  Y  ligament,  and  is  but 
a  slight  exaggeration  of 
the  anterior  oblique  luxa- 
tion (Fig.  33).  But  when 
the  bone  projects  fairly 
upon  the  abdomen  (as 
illustrated  by  the  dotted 
line.  Fig.  37),  only  the  in- 
ner fasciculus  remains. 

It  may  be  remarked  that 
the  anterior  oblique  disloca- 
tion, while  it  is  also  supra- 
spinous, differs  from  it  in 

the  comparative  soundness  of  the  ligament,  which  compels 
the  limb  to  assume  an  oblique  position.  In  the  latter  luxa- 
tion the  outer  band  is  broken,  and  the  limb  is  more  mova- 
ble ;  the  term  "  supra-.spinous  "  has  been  reserved  for  this,  as 
probably  the  more  common  of  these  two  rare  varieties. 


''M^ 


Fig.  39.1 


1  This  woodcut  is  intended  to  show  the  possibility  of  a  posterior  ob- 
lique luxation,  the  Y  ligament  being  entire,  the  head  of  the  bone  thrust 
across  it,  and  the  shaft  locked  behind  the  tuberosity.  In  the  dissected 
bones  it  will  be  found  that  the  femur  is  firmly  locked,  the  limb  being 
dii-ected  backward,  and  the  foot  somewhat  everted.  But  there  is  no 
authority,  so  far  as  I  am  aware,  to  show  that  such  a  position  of  the  leg 
has  been  found  in  the  liAnng  subject.  By  forcibly  advancing  the  knee 
the  outer  branch  of  the  ligament  is  ruptured,  and  the  luxation  then 
becomes  supra-spinous. 


94  EVERTED   DORSAL   DISLOCATION. 


REDUCTION. 

After  extension  bv  pulleys  in  the  axis  of  the  body  has  failed, 
reduction  of  this  luxation  has  been  accomplished  by  extension 
downward  and  outward,  with  some  manipulation  of  the  head 
of  the  bone  and  probably  with  rupture  of  the  ligament.  It  is 
obviously  a  better  plan  to  unhook  the  neck  by  circumduction 
of  the  extended  limb  inward,  with  eversion  enough  to  disen- 
gage it  from  the  edge  of  the  pelvis.  The  head  then  lies  upon 
the  dorsum,  and  if  the  outer  branch  of  the  Y  is  broken,  is  not 
inverted.  The  reduction  may  then  be  accomplished  as  usual 
in  the  dorsal  dislocation,  although  rotation  would  be  less 
effectual  than  if  the  ligament  were  entire.^ 

EVERTED    DORSAL    DISLOCATION. 

It  has  been  before  stated  that  inversion  of  the  limb  in  the 
dorsal  luxations  is  due  to  the  tense  outer  branch  of  the  Y 
ligament.  "When  the  injury  has  been  such  as  to  rupture 
these  fibres,  the  limb  may  still  be  inverted ;  but  it  can  also 
be  freely  everted.     Having  escaped  from   the  socket   under 

1  The  following  case  well  illustrates  the  mechanism  of  the  supra- 
spinous luxation,  and  is  taken  from  Hamilton  ("  Practical  Treatise," 
etc.,  p.  649) :  "  Lenta  relates  a  case  [of  ischiatic  luxation]  under  the 
care  of  Dr.  Hoffman,  in  the  New  York  City  Hospital,  in  which,  when 
the  extension  was  suddenly  relaxed  by  cutting  the  cord,  and  the  thigh 
at  the  same  instant  was  abducted  and  rotated  outward,  the  head  of  the 
femur  left  the  ischiatic  notch  and  rose  upon  the  dorsum  ilii,  assuming 
a  position  directly  above  the  acetabulum  and  below  the  anterior  supe- 
rior spinous  process,  from  which  position  it  was  with  great  difficulty 
subsequently  returned  to  the  socket." 

If  this  luxation  was  really  "  ischiatic,"  as  stated,  and  therefore  "  below 
the  tendon,"  the  forcible  outward  rotation  of  the  thigh  ruptured  both  the 
tendon  and  the  outer  part  of  the  Y  ligament,  or  in  any  case  the  latter  ; 
after  which  the  head  of  the  bone  was  free  to  turn  forward  and  rise  on  the 
ilium  toward  the  spine,  the  limb  being  of  course  everted,  and  the  head  of 
the  bone  perhaps  engaged  above  the  remaining  ligament. 


EVERTED   DORSAL   DISLOCATION. 


95 


these  circumstances,  the  bone  may  occupy  any  point  upon 
the  dorsum  within  the  range  of  the  inner  fasciculus.  The 
limb  is  then  shortened  in  proportion  to 
its  upward  displacement,  the  foot  being 
sometimes  everted  a  little,  sometimes 
lying  flat  upon  the  bed,  or  even  directed 
backward,  the  head  of  the  femur  facing 
accordingly,  and  —  as  has  been  else- 
where remarked  —  in  the  direction  of 
its  internal  condyle.  The  femur  is  sus- 
pended midway  between  the  inner 
branch  of  the  Y  and  the  obturator  ten- 
don. Theoretically  it  may  be  luxated 
either  below  or  above  this  tendon  ;  but 
in  the  former  case  the  degree  and 
nature  of  the  force  required  to  break 
the  outer  band  would  be  likely  to  rup- 
ture the  tendon  also.  If  the  head  of 
the  femur  is  driven  upward  and  back- 
ward above  the  obturator  tendon,  the 
same  forced  eversion  which  would  sever 
the   inner  branch  of   the  Y   ligament 

would  relax  this  tendon,  and  so  contribute  to  prevent  its  rup- 
ture. The  tendon  may  then  lend  its  aid  in  giving  position 
to  the  limb.2 

^  Everted  dorsal  dislocation.     (See  note,  p.  88.) 

2  For  an  old  case  of  this  sort,  with  an  analysis  of  the  muscular 
action,  see  a  paper  by  Dr.  Gordon  in  the  Dublin  Hospital  Gazette, 
Nov.  1,  184.5,  p.  87. 

Mr  G.  R.  Symes  has  described  a  case  ("  On  an  Unusual  Form  of  Dis- 
location of  the  Hip  Joint,"  by  Glasscut  R.  Symes,  one  of  the  Surgeons  of 
Stevens's  Hospital,  Dublin  Quarterly  Journal  of  Medical  Science,  1864, 
vol.  xxxviii.)  in  which  the  right  leg  was  shortened  two  inches,  the  foot 
extremely  everted,  the  buttock  flattened,  and  the  head  of  the  femur  two 
inches  below  the  anterior  superior  spinous  process  of  the  ilium.  The 
limb  remained  unreduced  after  protracted  efforts  by  manipulation  and 


Fig.  40.1 


96  EVERTED   DORSAL   DISLOCATION. 

REDUCTION. 

The  limb  should  be  flexed  and  inverted,  with  adduction  if 
necessary,  to  make  room  for  the  head  of  the  bone  to  slide 
upon  the  ilium  ;  and  the  dislocation  is  then  practically  a  simple 
dorsal  dislocation,  and  easily  reduced.  Or  if  not,  perhaps  the 
whole  upper  part  of  the  capsule  is  detached,  making  the  luxa- 
tion irregular. 

The  rupture  of  the  outer  fasciculus  of  the  Y  ligament 
deprives  the  operator  of  much  of  the  advantage  of  rotation. 
The  limb,  after  flexion  and  rotation  inward,  may  be  reduced 
by  direct  traction  toward  the  socket,  with  local  guidance.^ 

pulleys,  during  which  it  was  repeatedly  inverted  and  everted.  The  fail- 
ure to  reduce  the  limb  was  attributed  by  Mr.  Symes  to  a  "  button-hole  " 
laceration.  In  a  similar  case,  or  even  if  the  head  of  the  femur  were 
engaged  in  the  interstices  of  the  rotators,  I  should  attempt  to  liberate  it 
by  cu'cumducting  it  to  the  thyroid  foramen. 

A  case  of  everted  dorsal  dislocation  has  been  reported  by  Dr.  Van 
Buren  ("Contributions  to  Practical  Surgery,"  by  W.  H.  Van  Buren, 
M.  D.,  etc.,  Philadelphia,  1865,  p.  157).  The  limb  was  shortened  an  inch, 
and  slightly  everted,  there  being  some  obstacle  to  inversion.  The  tro- 
chanter was  an  inch  and  a  half  behind  and  above  its  usual  position,  and 
the  head  of  the  bone  was  obscurely  felt  in  the  back  part  of  the  sciatic 
notch.  After  repeated  attempts  at  reduction  by  manipulation,  the  bone 
was  reduced  by  pulleys  applied  to  the  thigh  in  a  flexed  position. 

For  a  case  probably  everted  dorsal,  but  classed  by  Cooper  as  anoma- 
lous, see  Morgan  (Guy's  Hospital  Reports,  No.  1,  p.  82).  The  left  leg 
was  shortened  two  inches,  the  foot  excessively  everted,  so  as  almost  to 
give  the  toes  a  direction  backward,  but  when  placed  side  by  side  with  the 
other  foot  remained  in  that  position.  The  leg  was  to  some  extent  sus- 
ceptible of  all  the  natural  motions,  with  the  exception  of  rotation.  The 
trochanter  could  not  be  felt ;  but  the  head  of  the  bone  was  apparently 
lying  between  the  anterior  inferior  spinous  process  of  the  ilium  and  the 
junction  of  that  bone  with  the  pubes.  Traction  was  made  from  the  knee 
against  counter-extension  with  the  foot  in  the  perinaeum.  The  patient 
was  then  directed  to  raise  his  shoulders  from  the  bed,  extension  was 
suddenly  increased  with  forcible  inward  rotation  of  the  thigh,  and  the 
head  snapped  into  the  socket. 

1  The  following  interesting  case  (reported  by  Dr.  Shrady  in  the  New 
York  Journal  of  Medicine,  March,  1860,  p.  255)  occurred  in  the  hospital 


IRREGULAR   DISLOCATIONS.  97 


IRREGULAR  DISLOCATIONS. 

IN   WHICH   THE    Y    LIGAMENT   IS   WHOLLY   BROKEN. 

In  rare  instances  the  Y  ligament  may  be  completely  rup- 
tured by  forced  extension  of  the  limb,  or  by  an  upward  thrust, 
while  the  lower  half  of  the  capsule  remains  comparatively 
sound.  But  it  has  been  shown  that  the  position  of  the  great 
majority  of  dislocations  is  determined  by  this  ligament ;  and 
until  it  is  likewise  shown  that  when  it  is  broken  the  luxated 
limb  will  be  compelled,  in  obedience  to  other  mechanical 
agents,  muscular  or  capsular,  to  assume  positions  equally 
constant,  it  is  fair  to  consider  such  luxations  as  irregular. 
When  any  mechanism  shall  be  shown  always  to  give  to  a  lux- 
ated limb,  after  the  Y  ligament  has  been  torn  asunder,  the 
same  position  under  the  same  circumstances,  the  luxation 
may  be  withdrawn  from  the  present  category,  and  classed  as 
"  regular." 

When  the  Y  ligament  is  wholly  broken,  and  the  head  of  the 
femur  is  dislocated  upward  upon  the  edge  of  the  socket,  either 

■wards  of  Dr.  Willard  Parker.  The  patient  was  crushed  to  the  ground 
by  a  gravel  car  falling  upon  the  small  of  his  back.  The  left  limb  was 
rotated  outward  and  shortened  three  inches,  the  thigh  slightly  adducted 
and  flexed,  the  knee  slightly  advanced  and  semi-flexed,  and  the  toe  so 
everted  that  the  heel  rested  against  the  inner  aspect  of  the  opposite  leg, 
just  above  the  ankle.  Passive  rotation  was  very  painful ;  the  buttock  of 
the  affected  side  was  much  fuller  than  the  other,  and  the  post-trochanteric 
depression  was  obliterated.  Only  the  tips  of  the  toes  touched  the  floor. 
The  vertical  distance  from  the  trochanter  to  the  crest  of  the  ilium  was 
shortened  three  quarters  of  an  inch.  (If  this  statement  is  correct,  the 
apparent  shortening  of  three  inches  was  probably  due  to  the  flexed  knee.) 
The  head  of  the  bone  could  be  felt,  but  not  very  distinctly,  in  a  direction 
forward  and  upward  from  the  trochanter.  Several  efforts  to  reduce  the 
limb  by  flexion  and  adduction  were  unsuccessful.  The  thigh  was  at  last 
rotated  inward,  extension  made  in  the  direction  of  the  socket,  and  the 
head  of  the  bone  guided  by  direct  manipulation  into  its  place. 


98  IRREGULAR   DISLOCATIONS. 

inside  or  outside  the  iliacus  tendon,  there  is  little  or  no  short- 
ening, and  no  flexion ;  but  the  eversion  of  the  foot  is  marked. 
The  head  is  felt  in  the  groin,  and  is  reduced  by  flexion  and 
inversion. 

If  the  head  of  the  bone  under  these  circumstances  be  dis- 
placed  toward  the  thyroid  opening,  there  is  abduction  of  the 
leg,  produced  chiefly  by  the  fascia  lata,  with  some  flexion  due 
to  the  adductors ;  but  the  flexion  is  less  than  in  the  regular 
thyroid  dislocation,  and  the  knee  can  be  depressed,  with  a 
little  effort,  to  the  natural  position.  It  is  possible  that  such  a 
dislocation  might  simulate  the  thyroid  displacement ;  but  it 
may  be  distinguished  from  this  by  the  greater  abduction  and 
less  considerable  flexion  of  the  limb. 

If  the  head  be  now  carried  farther  downward,  the  flexion 
becomes  more  considerable,  though  less  than  if  the  Y  ligament 
were  entire.  Such  may  have  been  the  condition  of  the  parts 
in  some  of  the  cases  of  downward  dislocation  before  referred 
to,  where  the  head  was  said  to  have  been  felt  near  the  tuber- 
osity, and  where  the  flexion  was  inconsiderable. 

If  the  head  of  the  bone  be  now  carried  behind  the  tendon  of 
the  obturator  internus  muscle,  there  is  a  flexion  of  the  femur 
at  an  angle  of  45°,  but  with  such  exaggerated  inversion  as  to 
distinguish  it  from  the  regular  dislocation  below  the  tendon. 
The  thigh  then  faces  completely  inward,  and  instead  of  cross- 
ing its  fellow  is  even  a  little  abducted.  The  leg,  which  is 
bent  by  the  tense  flexors  of  the  thigh,  stands  at  right  angles 
with  it. 

If  the  head  of  the  bone  be  carried  upward  upon  the  dorsum, 
the  limb,  while  it  faces  directly  inward  toward  its  fellow,  is 
no  longer  flexed,  as  in  the  regular  dorsal  dislocation,  but  lies 
flat  upon  the  table.  The  head,  being  now  detached  from  the 
socket,  may  be  carried  round  upon  the  dorsum  and  hooked 
above  the  rectus  muscle  in  front,  —  a  position  of  the  parts 
which,  owing  to  the  great  strength  of  the  Y  ligament,  is  prob- 


IRREGULAR  DISLOCATIONS.  99 

ably  less  frequent  than  the  regular  supra-spinous  and  everted 
dorsal  luxations,  where  a  portion  of  this  same  ligament  still 
remains  intact. 

The  Y  ligament  being  destroyed,  an  upward  and  back- 
ward dislocation,  if  attended  with  accidental  inversion,  may 
be  held  in  that  position  by  the  lower  part  of  the  capsule, 
which,  however,  is  readily  ruptured  by  outward  rotation 
or  circumduction. 

IRREGULAR   UPWARD   LUXATION. 

The  bone  may  be  thrust  upward  upon  the  inferior  spine  or 
above  it,  with  rupture  of  the  Y,  but  can  then  be  drawn  down 
as  far  as  the  remaining  capsule  will  allow,  unless  detained  by 
being  hooked  over  the  muscles  arising  from  that  point.^ 

1  For  several  cases,  of  which  the  description  is  incomplete,  but  in 
which  the  limb  was  rotated  outward,  the  head  of  the  femur  being  outside 
the  anterior  inferior  spinous  process  of  the  ilium,  see  Malgaigne's 
"  Traite,"  etc.,  p.  869.  In  a  patient  at  St.  George's  Hospital,  the  head 
of  the  bone  was  dislocated  upward  upon  the  inferior  spine  of  the  ilium, 
and  a  little  to  the  outside,  the  upper  half  of  the  capsule  being  largely 
torn.  (Lancet,  1840-41,  vol.  ii.  p.  281.)  In  Gerdy's  case,  reported  by 
Baron,  the  upper  haK  of  the  capsule  was  torn,  but  the  round  ligament  was 
only  half  broken.  In  this  case  the  limb  was  reduced  by  flexion,  the  head 
of  the  bone  being  pressed  toward  the  socket.     ("  Traite,"  etc.,  p.  870.) 

See  also  the  case  of  Adam  Hunter  (Edinburgh  Medico-Chu'urgical 
Transactions,  1824,  p.  171.)  The  limb  was  shortened  one  inch,  and  the 
toes  turned  inward.  The  head  of  the  bone  was  over  the  sciatic  notch, 
the  gluteus  minimus,  pyriformis,  obturator  internus,  and  other  small 
muscles  being  ruptm-ed.  The  capsule  was  entirely  detached  from  the 
femur,  so  that  when  the  ilio-femoral  muscles  were  divided  the  limb  was 
separated  from  the  trunk.  The  head  was  said  to  have  been  bound  down 
firmly  on  the  sacro-sciatic  notch  by  the  gluteus  medius,  which  passed 
over  the  neck  of  the  bone.  In  the  absence  of  the  capsule,  it  is  quite 
possible  that  the  gluteus  medius,  beneath  which  the  head  of  the  bone 
was  found,  together  with  the  anterior  flexors  of  the  thigh,  exercised  a 
certain  controlling  influence  on  the  position  of  the  limb ;  and  yet  after 
dividing  the  whole  capsule  in  a  recent  subject,  and  engaging  the  head 
of  the  femur  fairly  under  the  gluteus  medius  muscle,  I  have  found 
that  rotation  ruptured  its  fibres  with  little  effort. 


100  IRREGULAR  DISLOCATIONS. 


IRREGULAR   DOWNWARD   LUXATION.^ 

This  variety  should  be  distinguished  from  that  in  which  the 
Y  remains  entire,  —  described  in  connection  with  the  thyroid 
luxation.  In  the  latter  case  the  thigh  will  be  forcibly  flexed 
by  the  Y,  and  either  adducted  or  abducted,  while  the  head 
descends  even  to  the  tuberosity  or  perinaeum,  —  afterward, 
perhaps,  returning  to  be  lodged  near  the  thyroid  foramen,  or 
on  the  dorsum.  But  if  the  Y  be  wholly  broken,  the  limb  is 
suspended  by  the  remaining  and  comparatively  slender  cap- 
sule, which  in  such  a  case  would  probably  be  ruptured,  thus 
abandoning  the  limb  to  the  muscles.  Of  these,  the  psoas  and 
iliacus  offer  a  resistance  most  resembling  that  of  the  capsule, 
and  produce  an  imperfect  flexion.  The  biceps  and  other 
extensors  may  in  certain  positions  interfere  with  flexion,  as 
they  doubtless  do  in  the  regular  dislocation  downward,  while 
the  adductors  and  flexors  are  also  put  upon  the  stretch  when 
the  limb  is  extended  or  abducted.  It  has  been  elsewhere 
stated  that  the  muscles  inserted  immediately  about  the  hip 
are  subjected  to  the  very  powerful  leverage  of  the  femur,  and 
are  readily  ruptured  when  unsupported  by  the  ligament  of  the 
capsule.  The  same  is  true  in  a  less  degree  of  the  long 
muscles,  which  are  liable  to  laceration  from  the  great  violence 
necessary  to  sever  the  entire  capsule.  When  this  happens, 
the  bone  may  be  considered  as  fairly  torn  from  the  socket,  — 
a  grave  accident,  which  rarely  occurs,  and  in  which  the  limb 
assumes  no  uniform  position.  The  head  of  the  bone  might 
possibly,  in  such  a  case,  be  found  on  the  tuberosity  or  in  the 
perinaeum,  even  when  the  limb  is  extended. 

1  The  case  of  Keate  (see  p.  74)  may  have  been  irregular,  because  the 
operator  was  able  to  "  elongate  or  pull  down  the  limb "  after  reduc- 
tion, —  a  possibility  supposed  to  depend  on  a  fracture  of  the  socket, 
but  which  may  have  resulted,  if  correctly  reported,  from  a  rupture  of 
the  Y  ligament. 


OLD  DISLOCATIONS.  101 

REDUCTION. 

An  irregular  dislocation,  with  rupture  of  the  Y  ligament  if 
not  the  whole  of  the  capsule,  cannot  be  reduced  by  any  ro- 
tation which  depends  for  its  efficiency  upon  the  integrity  of 
these  ligaments.  On  the  other  hand,  their  ligamentous  fibres 
can  no  longer  interfere  with  a  direct  traction  of  the  femur 
toward  the  socket,  aided  by  local  guidance  if  required. 


SPECIAL   CONDITIONS   OF  DISLOCATION. 

OLD    DISLOCATIONS   AND   THEIR   REDUCTION, 

Cooper  ^  cites  a  case  of  dorsal  dislocation  said  to  have  been 
reduced  after  the  lapse  of  five  years  by  a  fall  from  a  berth  on 
shipboard.  Such  an  occurrence  is  by  no  means  impossible,  but 
would  depend  upon  the  condition  of  the  acetabulum,  and  of  the 
head  of  the  bone,  the  changes  in  which  would  be  influenced  by 
the  age  and  tendencies  of  the  patient.^  So  long  as  the  socket 
was  still  excavated,  and  the  bones  were  not  deformed  by  osse- 
ous growths,  I  should  feel  quite  confident  of  breaking  any  adhe- 
sions, lacerating  the  newly  formed  capsule,  and  replacing  the 
bone  by  the  great  power  of  the  femoral  shaft  as  a  lever,  and 
of  the  flexed  leg  in  rotating  the  head  of  the  bone  around  the 
main  ligament.-'^     I  am  unable  to  understand  why  Malgaigne, 

^  Treatise,  etc.,  Case  LXIY. 

2  For  a  case  of  dorsal  dislocation  reduced  after  eight  months,  see  p.  .5.3. 

3  The  following  passage  corroborates  the  views  here  advanced,  al- 
though its  writer  does  not  recognize  the  capsule  as  a  source  of  resistance 
to  reduction :  — 

"  It  is  doubtful  if  the  capsule  is  ever  an  obstacle  to  the  return  of  the 
•dislocated  bone.  Certainly  the  altered  shape  of  the  head  of  the  bone 
never  can  prevent  the  retui'u  of  the  head  to  its  articular  cavity ;  and  it 
is  probable  that  where  the  articular  cavity  is  partially  obliterated,  it  is 


102  OLD  DISLOCATIONS. 

as  quoted  by  my  distinguished  friend  M.  Broca,^  in  the  dis- 
cussion elsewhere  alluded  to,  should  assign  an  indefinite  period 
of  two  years  or  more  as  the  limit  for  reducing  a  dorsal  dislo- 
cation, and  only  fifteen  days  for  that  upon  the  ischiatic  notch. 
By  the  flexion  method,  the  latter  luxation  should,  theoretically, 
be  reduced  with  even  more  facility  than  the  former,  and  after 
as  long  an  interval. 

A  difficulty  that  may  be  seriously  considered  is  the  risk  of 
breaking  the  femoral  neck,  if  it  has  undergone  fatty  degene- 
ration or  atrophy  from  long  disuse ;  and  it  might  be  well  in 
such  a  case  to  rely  rather  on  traction,  or  other  force  exerted 
longitudinally  upon  the  bone,  than  on  rotation,  where  from 
the  immense  power  thus  laterally  applied  the  neck  is  taken 
at  great  disadvantage.  The  angular  traction,  to  be  hereafter 
described,  would  be  especially  suitable,  —  although,  from  the 
greater  facility  of  such  an  application  of  power,  a  better  result 
might  be  anticipated  in  a  dorsal  or  downward  than  in  an  old 
pubic  or  even  thyroid  luxation.  Yet  should  fracture  of  the 
neck,  or  separation  of  a  previous  fracture,  occur  during  such 
attempts  at  reduction,  it  may  be  fairly  said  that  the  patient 
will  generally  have  a  better  limb  after  its  inversion  has  been 
thus  corrected  than  with  an  unreduced  luxation. 

An  illustration  of  these  points  is  afforded  by  a  case  in  the 
Chelsea  Marine  Hospital,  under  the  charge  of  Dr.  Graves. 
The   patient,  a   man   twenty-three   years    of   age,  about   six 

the  ]-esult  of  extraordinary  violence  and  consequent  inflammation.  I 
have  found  the  cotyloid  cavity  retaining  its  depth  and  covered  with  carti- 
lage after  the  head  of  the  femur  had  been  dislocated  for  three  years ; 
and  Fournier  has  placed  a  dissection  on  record  where  the  head  of  the 
femur  had  been  dislocated  during  thirteen  years,  and  in  which  the  ace- 
tabulum retained  its  form  and  depth  and  cartilage.  (Bulletin  de  la 
Societe  Anatomique,  1855.)"  — Bernard  E.  Brodhurst  :  On  the  Re- 
duction of  Old  Dislocations  (St.  George's  Hospital  Reports,  vol.  iii.  1868. 
London. 

1  Union  Medicale,  No.  79,  p.  57. 


OLD   DISLOCATIONS.  103 

months  before  entering  the  Hospital,  had  fallen  from  the 
mast-head,  seventy-five  feet,  striking  the  thwart  of  a  boat 
(which  was  broken  by  the  fall)  and  dislocating  his  left  hip. 
No  attempt  was  made,  at  the  time  of  the  accident  (Nov.  8, 
1862)  to  reduce  the  displacement.  At  the  time  of  entering 
the  Hospital  the  patient  was  wholly  unable  to  walk,  being 
carried  and  placed  in  bed,  where  he  remained.  The  limb  was 
shortened  about  two  inches,  slightly  flexed,  and  inverted  to 
such  a  degree  that  the  patella  faced  the  inside  of  the  opposite 
thigh,  and  the  toes  of  the  affected  limb  were  more  easily 
placed  behind  the  heel  of  the  other  foot  than  upon  the  instep. 
The  patient  could  partially  flex  the  thigh,  and  also  extend  it 
nearly  flat  upon  the  bed,  and  could  rotate  the  limb  inward, 
but  could  not  evert  it.  The  head  of  the  bone  was  readily  felt 
upon  the  dorsum.  Dr.  Graves  having  kindly  placed  the  man 
under  my  charge  for  the  reduction  of  the  dislocation,  I  flexed 
the  limb  once  slowly  upward  upon  the  abdomen,  —  a  move- 
ment which  was  attended  with  a  continued  fine  crepitation 
about  the  hip.  Upon  examination,  the  head  of  the  bone  was 
now  felt  to  be  detached  from  the  neck,  and  freely  movable, 
like  a  grape-shot,  among  the  muscles  of  the  haunch.  The 
patient  was  thereupon  placed  in  bed,  the  position  of  the 
extended  limb  being  much  the  same  as  before  manipulation. 
In  the  course  of  a  week  the  foot  was  gradually  everted,  after 
which  extension  was  applied  and  maintained  during  three 
months,  being  increased  by  degrees  from  seven  pounds  to 
about  twenty-one.  In  two  weeks  from  this  time  the  patient 
began  to  move  about  on  crutches,  which  after  six  weeks  more 
were  abandoned,  and  at  the  end  of  two  years  he  was  able  to 
walk  without  a  cane.  The  limb  is  now,  six  years  after  the 
accident,  an  inch  and  a  half  shorter  than  its  fellow,  but  other- 
wise in  proper  position,  and  moves  freely  in  all  directions, 
although  it  cannot  be  everted  much  beyond  the  perpendicular. 
The  head  is  firmly  attached  to  the  femur  behind  the  trochanter, 


104  DISLOCATION  FROM  HIP  DISEASE. 

and  seems  with  the  latter  to  cover  the  acetabulum.  The 
manipulation  in  this  case  was  conducted  in  the  presence  of  a 
considerable  number  of  medical  gentlemen ;  and  the  manner 
in  which  the  head  was  detached  from  the  shaft  left  no  doubt 
upon  their  minds  that  the  neck,  as  the  result  either  of  an 
original  fracture  or  of  subsequent  inflammatory  action,  had 
not  its  normal  strength.  On  the  other  hand,  the  present  con- 
dition of  the  patient  is  much  better  than  it  would  have  been 
had  not  the  dislocation  been  treated.  He  walks  freely  and 
firmly,  with  but  little  lameness,  runs  up  and  down  stairs,  and 
can  swing  the  limb  in  all  directions. 

DISLOCATION    PROM    HIP   DISEASE. 

In  the  dorsal  luxation  which  follows  aggravated  hip  disease, 
the  anterior  part  of  the  capsular  ligament  usually  supports 
and  inverts  the  shortened  limb.  On  the  other  hand,  the  head 
of  the  femur,  which  rests  upon  the  dorsum  of  the  ilium,  pro- 
duces, when  disintegrated  by  disease,  less  inversion  than  if  it 
were  of  normal  size.  Again,  the  displacement  is  generally  a 
sub-luxation ;  but  it  may  sometimes  be  complete.  In  a  case 
of  hip  disease,  occurring  in  a  boy  about  ten  years  of  age, 
which  terminated  fatally,  I  excised  the  head  of  a  femur  (the 
first  instance  of  this  operation  in  the  United  States)  that  was 
completely  dislocated  upon  the  dorsum. 

The  following  is  an  instructive  case  of  dislocation,  perhaps 
connected  with  hip  disease,  and  reduced  by  manipulation. 

The  patient  was  a  feeble  and  slender  boy  thirteen  years  of 
age,  who  was  said  to  have  dislocated  his  hip  upon  the  dorsum 
by  a  fall  upon  a  barn  floor  about  three  months  before,  and 
whom  I  was  requested  to  see  in  consultation.  The  head  of 
the  bone  could  be  plainly  felt  upon  the  dorsum,  the  limb  being 
as  usual  inverted,  shortened,  and  a  little  flexed.  I  found  that 
in  abducting  the  limb  after  it  was  flexed,  a  very  considerable 
force  was  required  to  raise  the  head  over  the  socket,  and  still 


DISLOCATION  FROM   HIP  DISEASE.  105 

more  in  outward  rotation  to  make  it  enter,  which  it  did  only 
after  the  capsule  and  other  attachments  had  been  freely  lacer- 
ated. After  reduction,  the  head  of  the  bone  readily  and 
repeatedly  escaped,  and  could  be  kept  in  place  only  by  the 
expedient,  elsewhere  alluded  to,  of  confining  the  limb.  The 
foot  was  secured  to  the  inside  of  the  sound  knee,  and  the 
limb,  thus  flexed,  was  abducted  down  to  the  level  of  the  bed, 
where  it  was  bound  to  the  side  of  the  bedstead  by  a  folded 
sheet  under  the  knee.  In  this  constrained  position  of  flexion, 
abduction,  and  eversion,  the  patient  remained  for  two  and  a 
half  weeks,  when  I  again  saw  him,  and  found  the  bone  in 
place.  But  soon  the  hip-joint  became  stiff  and  painful,  and 
sinuses  slowly  formed  and  opened  in  the  groin,  as  if  from  hip 
disease.  Upon  inquiry,  it  was  ascertained  that  the  child  had 
suffered  from  pain  near  the  hip  after  a  fall  the  preceding  year, 
and  had  also  lately  recovered  from  protracted  and  grave  dis- 
ease of  the  bone  near  the  ankle.  The  dislocation  may  or  may 
not  have  been  facilitated  by  this  tendency  to  disease  of  the 
bone;  but  there  can  be  little  doubt  that  serious  inflammatory 
action  was  awakened  by  the  presence  of  the  reduced  femur  in 
the  socket. 

DISLOCATION   OF   THE   HIP,   WITH    FRACTURE   OF   THE   SHAFT 
OF    THE    FEMUR. 

Cases  have  been  reported  of  fracture,  even  of  the  upper 
third  of  the  shaft,  in  which  an  accompanying  dislocation  was 
reduced  by  manipulation.  There  seems  to  be  no  good  reason 
why,  after  the  firm  application  of  lateral  splints  to  the  thigh, 
the  attempt  should  not  be  made  with  entire  success,^  —  reli- 
ance being  especially  placed  upon  flexion  and  the  local  man- 
agement of  the  head  of  the  bone,  which  may  be  guided  into 
its  socket  by  the  hands  of  the  operator  applied  directly  to  it, 
or  by  a  towel  in  the  groin.     Angular  extension  of  the  lower 

1  See  Hamilton'.s  "  Practical  Treatise,"  etc.,  p.  666. 


106  SPONTANEOUS   DISLOCATION. 

fragment  of  the  femur  may  draw  upon  its  upper  muscular 
insertions,  and  likewise  make  room  for  the  upper  fragment  to 
follow  it ;  but  it  is  obvious  that  nothing  can  be  effected  by  its 
rotation. 

SPONTANEOUS   DISLOCATION. 

Cases  have  been  cited  of  individuals  who  could  partially 
luxate  and  reduce  the  head  of  the  thigh-bone  at  will,  b}*  the 
action  of  the  muscles  of  the  hip,  Hamilton  has  collected 
three  such  cases. ^  I  have  had  an  opportunity  of  examining 
two,  and  Dr.  Lyman,  of  Boston,  has  communicated  to  me  the 
details  of  a  third,  all  of  which  were  dorsal  luxations. 

In  the  first  of  these  cases,  —  that  of  a  soldier  under  the 
charge  of  Dr.  Langmaid,  to  whom  I  am  indebted  for  the 
opportunity  of  examining  it,  —  the  hip  was  dislocated  while 
the  legs  were  crossed,  a  wagon  in  which  the  man  was  riding 
having  pitched  into  a  hole.  In  a  few  hours  the  hip  was 
reduced  by  flexion.  Eight  days  after  the  accident,  in  attempt- 
ing to  walk  upon  the  limb,  it  was  again  partially  luxated,  — 
when  the  patient  himself  replaced  it  by  pushing  against  it 
with  one  hand  and  pressing  with  the  other  against  his  knee. 
Since  that  time  both  luxation  and  reduction  have  been  com- 
paratively easy,  and  the  patient  now  displaces  the  head  of  the 
bone  backward  upon  the  edge  of  the  socket  by  muscular 
action,  and  reduces  it  by  "  throwing  the  leg  out  sideways." 
The  luxation  is  sometimes  attended  with  pain,  and  the  promi- 
nence caused  by  the  head  of  the  luxated  bone  is  sensitive  to 
the  touch.  In  this  and  the  following  case,  the  displacement 
is  rather  a  sub-luxation  ;  and  the  limb  exhibits  slight  flexion, 
shortening,  and  inversion. 

In  the  second  case,  —  that  of  a  gentleman  formerly  of 
Boston,  —  the  phenomena  are  much  like  those  just  described ; 
the  bone  being  slipped  out  and  in  upon  the  dorsal  edge  of  the 
socket  by  muscular  action  at  will. 

^  Practical  Treatise,  etc.,  p.  644. 


SPONTANEOUS  DISLOCATION. 


107 


A  third  case  was  under  the  care  of  Dr.  E.  M.  Moore,  of 
St.  Mary's  Hospital,  Rochester,  N.  Y.,  who  has  published 
photographs  of  it,  from  which  the  annexed  figures  are  taken. 
The  following  account  of  this  case  has  been  kindly  furnislied 
me  by  Dr.  G.  H.  Lyman,  of  Boston,  who  obtained  it  from  Dr. 
Moore :  — 


Fiff.  41.1 


Fig.  42. 


"John  B.  Parker,  private,  Co.  H,  148th  New  York  Volunteers, 
while  on  the  march  from  Bermuda  Hundred  to  Drury's  Bluff,  May 
13,  1864,  was  skirmishing  up  a  hill,  and  sprang  back  suddenly  to 
avoid  the  gun  of  a  comrade  in  advance.  His  left  foot  became 
entangled,  and  his  weight  dislocated  his  hip.  He  felt  the  injury, 
and  supposed  it  out  of  joint.  Some  comrades  pulled  it  in.  He 
immediately  resumed  his  skirmishing,  and  marched  seven  miles, 
from  10  A.  M.  till  6  p.  m.  He  lay  down  at  night,  and  went  on 
duty  the  next    day,   sharp-shooting,   crawling    all    day.     He    con- 


Spontaneous  luxation  of  the  thigh.     Dr.  Moore's  case. 


108  FRACTURE   OF  THE   PELVIS. 

tinued  this  kind  of  duty  five  da^'^s,  and  returned  to  camp,  when  he 
was  immediately  put  on  intrenchments,  and  worked  two  days  and 
nights.  Afterward  he  went  on  picket,  and  entered  the  hospital 
May  28.  At  present  he  can  luxate  the  hip-joint  at  any  time,  and 
does  it  by  pressing  the  foot  on  the  floor  to  fix  it  firmly,  contract- 
ing the  adductors,  and  throwing  out  the  pelvis.  The  head  suddenly 
leaves  the  acetabulum,  and  goes  on  the  dorsum  ilii." 

Although  the  lateral  displacement  and  slight  inversion 
show  that  this  is  only  a  sub-luxation,  with  the  head  upon  the 
edge  of  the  socket,  yet  the  flexion  of  the  limb,  due  to  the  elas- 
ticity and  comparative  integrity  of  the  living  tissues,  makes  it 
perhaps  a  better  representation  of  a  common  dorsal  luxation 
than  Fig.  4,  which  was  photographed  from  the  dead  subject, 
and  where  the  limb  was  purposely  extended  as  far  as  the  Y 
lio-ament  would  allow. 


FRACTURE  OF  THE  PELVIS. 

The  following  remarks  on  fracture  of  the  pelvis  are  intro- 
duced here,  chiefly  with  the  view  of  showing  how  far  this 
injury  may  be  mistaken  for  regular  dislocation  of  the  hip. 
With  this  view  the  subject  has  been  divided  into  four  heads, 
comprising,  respectively  :  (1)  Fracture  of  the  rim  of  the  ace- 
tabulum ;  (2)  Fracture  in  which  the  head  of  the  bone  is  driven 
through  the  acetabulum  into  the  pelvis ;  (3)  kSuspected  fracture 
of  the  acetabulum ;  (4)  Fracture  of  other  parts  of  the  pelvis. 
A  few  cases  are  given  in  illustration  of  each  of  these  lesions. 
The  more  instructive  of  these  are,  of  course,  such  as  have 
been  verified  by  autopsy.  But  there  are  some  which  are  au- 
thenticated only  by  well-marked  crepitus,  and  perhaps  by  mo- 
bility of  the  detached  fragment;  and  it  is  then  important 
that  crepitus  should  not  be  confounded  with  the  grating 
which  results  from  the  attrition  of  unbroken  bone  or  cartilage. 


FRACTURE   OF  THE   PELVIS.  109 

Finally,  there  are  still  others,  and  by  far  the  most  numerous, 
in  which  a  fracture  of  the  socket  has  been  inferred  only  from 
a  supposed  impossibility  of  reducing  the  luxated  femur,  or  of 
retaining  it  in  place  after  reduction.  It  need  not  be  said  that 
these  last  cases  are  more  conclusive  to  the  observer  than  to 
the  reader. 

FRACTURE  OP  THE  RIM  OF  THE  ACETABULUM. 

To  afford  satisfactory  evidence,  cases  of  this  sort  should 
have  been  identified  by  autopsy,  or  at  least  by  crepitus. 
Unfortunately,  but  a  small  part  of  the  reported  cases  are  thus 
elucidated,  and  fracture  has  been  generally  inferred  because 
the  head  of  the  bone  could  not  be  restored  to  the  socket,  or 
could  not  be  kept  there.  It  is  probable  that  when  the  rim  of 
the  socket  is  broken  on  the  side  either  of  the  dorsum  or  of  the 
foramen  ovale,  the  signs  of  the  displacement  do  not  vary 
materially  from  those  of  the  regular  luxations.  The  regular 
backward  displacement,  for  example,  may  be  complicated  with 
a  detached  rim,  which,  if  enough  be  left  to  engage  the  head  of 
the  bone,  in  no  way  interferes  with  its  conditions  as  a  luxation, 
except  that  the  bone  tends  to  slip  backward  after  being  reduced. 
The  same  principle  probably  holds  true  in  the  case  of  fracture 
of  the  rim  on  the  side  of  the  foramen  ovale,  and  also  of  the 
upper  part  of  the  socket,  unless  the  fracture  involves  the  upper 
insertion  of  the  Y  ligament,  in  which  case  the  detached  frag- 
ment might  be  so  displaced  as  materially  to  modify  the  position 
of  the  limb,  especially  so  far  as  its  flexion  or  inversion  was  con- 
cerned.    Such  a  luxation  would  be  irregular. 

These  displacements,  especially  the  displacement  backward, 
demand  the  usual  attempts  at  reduction  by  flexion.  Although 
the  bone  inclines  to  slip  from  the  socket,  it  can  be  retained 
there,  in  cases  of  a  sort  heretofore  considered  difficult  of  treat- 
ment, by  angular  extension,  with  an  angular  splint  attached 
to  the  ceiling  or  some  other  point  above  the  patient ;  or  if  any 


110  FRACTURE   OF   THE   PELVIS. 

manoeuvre  has  reduced  the  bone,  the  limb  should  be  retained, 
if  possible,  in  the  attitude  which  completed  the  manoeuvre.^ 

The  following  case  occurred  at  the  Massachusetts  General 
Hospital,  under  the  care  of  Dr.  Gay.  The  patient,  aged  thirty- 
six,  a  robust  and  healthy  man,  fell  from  the  roof  of  a  building, 
striking  upon  the  right  hip.  In  the  recumbent  position  the 
leg  was  shortened  and  inverted,  the  toes  crossing  the  opposite 
instep.  Being  etherized,  the  thigh  could  be  flexed  at  a  right 
angle  with  the  abdomen,  there  being  crepitus  in  the  region  of 
the  neck  of  the  femur.  The  limb,  when  drawn  down,  was  still 
shortened  half  an  incli.  The  patient  having  died  of  other 
injuries,  the  autopsy  showed  the  head  of  the  bone  partially 
dislocated  backward,  and  resting  upon  the  posterior  fractured 
edge  of  the  socket,  the  whole  posterior  wall  of  the  socket  hav- 
ing been  broken  away  in  a  mass.  The  detached  fragment 
measured  one  and  a  half  inches  square.  The  posterior  surface 
of  the  head  of  the  bone  was  deeply  indented  by  the  fractured 
edge  of  the  acetabulum,  against  which  it  had  impinged  after 
displacing  the  portion  broken  off.  A  transverse  crack  ex- 
tended through  the  acetabulum  from  the  upper  sciatic  notch 
to  the  foramen  ovale.  The  position  of  the  limb  in  this  case 
did  not  differ  from  that  in  the  usual  partial  dislocation  behind 
the  tendon,  and  was  determined  by  the  same  mechanism.^ 

1  See  p.  53. 

-  In  a  case  of  dorsal  luxation  with  inversion,  reported  by  Maisonneuve 
(Clinique  Chirurgicale,  186;],  p.  168),  the  autopsy  showed  fracture  of  the 
posterior  part  of  the  border  of  the  socket. 

Sir  Astley  Cooper's  Case  No.  LXXI.  is  one  of  regular  dislocation  below 
the  tendon  of  the  obturator  internus,  which  tightly  embraced  the  neck 
of  the  bone,  with  shortening  and  inversion  of  the  limb,  although  the  pos- 
terior part  of  the  acetabulum  was  broken  off,  and  there  was  other  extensive 
fi-acture  of  the  pelvis. 

Dr.  M.  Tyer's  third  case  was  shown  by  the  autopsy  to  be  a  regular 
backward  dislocation  with  inversion,  —  the  posterior  and  inferior  margin 
of  the  acetabulum  being  detached,  and  displaced  toward  the  coccyx. 

On  the  other  hand,  in  Dr.  Tyer's  first  case,  the  limb  was  everted  while 


FRACTURE   OF  THE   PELVIS.  Ill 

FRACTURE   IN  WHICH    THE    HEAD    OF    THE    FEMUR    IS    DRIVEN 
THROUGH    THE    ACETABULUM. 

In  regard  to  this  accident  Hamilton  well  remarks  :  — 

''There  seems  to  be  no  certain  rule  in  relation  to  the  position 
of  the  limb ;  but  it  is  found  to  take  the  one  direction  or  the  other, 

flexed  and  shortened,  an  inch  and  a  half  of  the  rim  being  completely 
detached  at  the  upper  and  posterior  margin  of  the  acetabulum.  The 
remaining  portion  of  the  rim  may  not  have  been  sufficient  to  turn  the 
head  backward,  and  thus  compel  inversion  of  the  limb.  In  a  second  case, 
the  toes  crossed  the  tarsus  of  the  other  foot,  and  the  autopsy  showed  a 
fracture  of  the  upper  margin  of  the  rim  of  the  acetabulum,  (Glasgow 
Medical  Journal,  February,  1830 ;  American  Journal  of  the  Medical  Sci- 
ences, 1831,  vol.  viii.  p.  517.) 

For  a  case  of  dorsal  luxation  with  shortening,  inversion,  crepitus,  and 
diflicvilty  of  retaining  the  reduced  bone  in  the  socket,  see  Cooper's  "Trea- 
tise," etc.,  Case  XXXIX. 

In  the  following  case  of  fractured  acetabulum,  the  upper  insertion  of 
the  Y  ligament  was  detached.  The  patient,  fifty-eight  years  of  age,  was 
caught  by  a  revolving  belt.  The  right  limb  was  shortened  a  quarter  of 
an  inch,  and  so  far  everted  and  straight  that  the  internal  condyle  of  the 
left  femur  lay  in  the  popliteal  space  of  the  injured  one.  The  right  groin 
was  filled  up.  Toward  its  middle,  and  outside  the  femoral  artery,  was  a 
hard,  resisting,  and  obscurely  spherical  tumor,  masked  by  the  glands  and 
swollen  tissues.  Flexion  with  outward  rotation  and  local  downward 
pressure  failed  to  reduce  the  luxation ;  but  on  a  third  trial,  flexion  and 
downward  pressvire  during  slight  abduction,  instead  of  outward  rotation, 
succeeded.  Seven  months  afterward,  the  death  of  the  patient  from  another 
cause  showed  a  united  fracture  of  the  socket,  comprising  the  external  and 
anterior  third  of  the  rim  with  the  two  anterior  spinous  processes  of  the 
ilium.  (M.  Beraud,  Bulletm  de  la  Societe  de  Chirurgie,  1862,  torn.  iii. 
p.  185.)  • 

In  the  above  case  reported  by  M.  Richet,  the  trochanter  was  rotated 
toward  the  median  line,  with  the  head  of  the  femur  facing  directly  for- 
ward, and  probably  with  displacement  of  the  detached  bone.  But  the 
fact  that  the  round  ligament  was  unbroken  would  seem  to  indicate  that 
the  luxation  was  only  partial,  as  might  indeed  have  been  inferred  from 
the  position  of  the  limb,  which,  though  everted,  was  not  much  displaced. 

In  this  connection,  M.  Richet  (Bulletin,  p.  226)  refers  to  a  case  of  luxa- 
tion of  Maisonneuve  (Re\T^ie  Medico-Chirm-gicale,  tom.  xvi.  p.  48)  in  which 
a  fragment  of  a  broken  acetabulum  had  in  twenty-seven  dajs  united  with 
the  rest  of  the  rim  so  firmly  that  the  fracture  could  hardly  be  discovered. 


112  FRACTURE   OF   THE   PELVIS. 

probably  according  to  the  direction  of  the  force  which  has  inflicted 
the  injury,  and  perhaps  in  obedience  to  circumstances  not  always 
to  be  explained."  ^ 

In  two  of  the  recorded  cases  the  patients  recovered,  beins^ 
able  to  walk ;  in  one  of  these  the  head  of  the  femur  had 
become  almost  completely  inclosed  in  a  bony  shell.  In  two 
other  cases  the  patients  died  of  the  injury,  which  in  all  was 
the  result  of  great  local  violence.^ 

It  may  be  remarked  that  when  the  head  of  the  femur  is 
thus  thrust  completely  within  the  pelvis,  the  capsule  and  sur- 
rounding muscles  are  relaxed,  and  would  not  determine  the 
position  of  the  bone. 

ASSERTED  FRACTURE  OF  THE  ACETABULUM,  WITHOUT  CREPITUS, 
FROM  A  SUPPOSED  IMPOSSIBILITY  OP  KEEPING  THE  FEMUR  IN 
PLACE. 

It  has  been  already  remarked  that  the  evidence  in  this  class 
of  cases  is  unsatisfactory ;  and  it  is  not  unlikely  that  the  bone 
could  have  been  kept  in  place  by  angular  extension  when 
other  means  had  failed,  or  by  confining  the  leg  in  the  position 
of  the  final  manoeuvre  by  which  it  was  reduced,  as  before 
described.^ 

1  Practical  Treatise,  p.  .34-3. 

2  In  the  case  of  Lendrick,  and  that  of  Morel-Lavallee,  the  accident  was 
supposed  to  be  that  of  fracture  of  the  neck,  from  which  it  may  be  inferred 
that  the  foot  was  everted.  In  Case  LXXII.  of  Cooper,  the  appearance  was 
that  of  dislocation  backward,  probably  involving  inversion.  In  that  of 
Moore  the  limb  was  shortened  two  inches,  slightly  flexed  and  abducted, 
but  without  rotation  in  either  direction.  Cooper,  "  Treatise,"  etc..  Cases 
LXXII.  and  LXXIII. ;  Lendrick,  American  Journal  of  the  Medical  Sci- 
ences, August,  1839,  vol.  xxiv.  p.  481  (from  London  Medical  Gazette, 
March,  1839);  Morel-Lavallee,  Malgaigne,  "Traite,"  etc.,  tom.  ii.  p.  881; 
Moore,  Medico-Chirurgical  Transactions,  18.'51,  vol.  xxxiv.  p.  107. 

3  See  p.  53.  In  the  case  of  Keate  (Cooper,  "  Treatise,"  etc..  Case 
LXIX.),  the  fact  that  the  limb  could  be  drawn  down,  together  with  doubt- 
ful crepitus,  was  regarded  as  evidence  of  fracture  of  the  socket.     For  a 


FRACTURE   OF  THE   PELVIS.  113 

FRACTURE    OF   OTHER   PARTS   OF   THE   PELVIS. 

A  fracture  of  the  pelvis  not  especially  involving  the  aceta- 
bulum can  hardly  be  mistaken  for  luxation  of  the  hip ;  and 
yet  the  following  case  under  my  care  may  be  cited  as  an  in- 
stance of  a  limb  the  position  of  which,  when  first  seen,  was 
identical  with  that  of  a  dislocation,  and  as  in  similar  cases 
was  probably  due  to  an  effort  of  the  patient  to  relieve  the  pain 
of  injured  tissues.^ 

The  patient,  a  young  man  of  seventeen  years  of  age,  entered 
the  Massachusetts  General  Hospital,  having  been  caught  be- 
neath a  heavy  piece  of  machinery  which  fell  from  a  wagon, 
striking  upon  the  front  of  his  left  thigh  just  below  the  groin. 
Upon  examination  the  thigh  was  found  to  be  flexed  upon  the 
pelvis,  and  the  foot  everted.     The  knee  was  widely  separated 

case  of  Mr.  Brodie,  of  twelve  weeks'  standing,  where  failure  to  reduce  a 
dorsal  dislocation  was  attributed  to  fractvu'e  of  the  socket,  although 
none  of  its  indications  were  present,  see  the  Lancet,  vol.  xxiv.  p.  671. 

The  following  case  of  supposed  fractured  socket  without  crepitus  is 
one  of  several  reported  by  M.  Richet.  A  young  man  fell  in  dancing,  while 
endeavoring  to  fling  up  his  leg  to  the  level  of  his  partner's  face.  The  leg 
was  much  inverted,  and  three  quarters  of  an  inch  shortened,  the  head  of 
the  femur  being  felt  upon  the  dorsum.  The  bone  was  repeatedly  reduced, 
and  as  often  escaped.  The  patient  was  ultimately  placed  in  a  fracture 
apparatus  with  extension,  and  two  years  after  walked  lame,  the  head  of 
the  bone  rising  upon  the  ilium  at  each  step.  No  crepitus  was  felt,  the 
diagnosis  being  based  upon  the  supposed  impossibility  of  keeping  the 
head  in  the  socket.  (Bulletin  de  la  Societe  de  Chirurgie,  1862,  tom.  iii. 
p.  251.) 

1  A  case  of  fracture  of  the  ilium  yielded  crepitus  under  pressure  upon 
the  anterior  and  upper  part  of  the  ilium,  the  leg  being  shortened  three 
quarters  of  an  inch,  and  the  foot  slightly  everted.  After  extension  by  the 
double  inclined  plane  for  several  weeks  the  deformity  disappeared.  (Lan- 
cet, vol.  xliv.  J).  877.) 

In  a  case  of  fracture  of  the  ilium,  the  right  leg  was  half  an  inch  shorter 
than  the  left,  and  slightly  everted,  with  flattening  of  the  region  of  the 
trochanter,  the  knee  being  also  abducted.  Pressure  on  the  anterior  supe- 
rior spine  produced  crepitus  attended  with  acute  pain  in  the  joint.  (Lan- 
cet, vol.  XV.  p.  575.) 


114  ANGULAR  EXTENSION. 

from  the  other,  any  attempt  to  approximate  them  causing 
pain.  The  pubes  was  tender  when  pressed.  Under  ether  the 
leg  resumed  its  normal  position.  No  crepitus  was  discovered, 
although  the  patient  had  complained  of  a  sense  of  grating  in 
the  perinaeum.  A  broad  strap  was  placed  around  the  pelvis, 
and  in  six  weeks  the  patient  was  well  enough  to  be  discharged, 
walking  on  crutches.  It  is  difficult  in  this  case  to  account  for 
the  position  of  the  limb  before  etherization,  except  on  the  sup- 
position that  it  may  have  afforded  relief  to  pain.  To  the  eye 
its  position  was  that  of  a  thyroid  luxation.^ 


ANGULAR  EXTENSION. 

PouTEAU^  first  remarked  upon  the  disadvantage  of  traction 
with  counter-extension  in  the  perinaeum,  which  brings  the 
thigh  into  a  straight  line  with  the  trunk.  Most  surgeons 
have  observed  the  tendency  of  the  pelvis,  when  pulleys  are 
used,  to  escape  from  the  counter-extending  bands  in  the 
direction  of  the  applied  traction.  It  is  believed  that  the 
apparatus  here  described  will  be  found  efficient,  both  in  con- 
fining the  pelvis  and  in  enabling  the  operator  to  apply  ex- 
tension to  a  limb  which  has  been  flexed  for  the  purpose  of 
relaxing  the  Y  ligament.  Lateral  extension,  with  or  with- 
out pulleys,  can  then  be  made  in  any  desired  direction  by  a 
towel  passed  round  the  thigh  at  the  groin. 

The  patient  being  laid  upon  his  back,  the  pelvis  is  secured 
to  the  floor  by  a  T  band  passing  across  it  laterally  in  front, 
between  the  superior  and  inferior  spinous  processes  of  each 
side,  and  vertically  over  the  pubes  and  perinaeum.  The  three 
extremities,  each  terminating  in  a  strap  and  buckle,  are 
fastened  to  the  floor  beneath  the  margin  of  the  pelvis  by 

1  Massachusetts  General  Hospital  Records,  vol.  cxxvii.  p.  210. 

2  Malgaigne,  "  Traite,"  etc.,  p.  867. 


ANGULAR   EXTENSION. 


115 


common  dislocation-hooks.  The  entire  band,  with  the  excep- 
tion of  its  extremities,  is  cyhndrical,  about  two  inches  in 
diameter,  well  padded  and  covered  with  buckskin.  It  firmly 
holds  the  pelvis  by  its  pressure  between  the  spinous  processes 
on  each  side  and  upon  the  pubes.  To  apply  it,  the  three 
pointed  hooks  are  screwed  into  the  floor,  one  near  each  tro- 


FiG.  43.1 


chanter,  and  one  near  the  perinaeum ;  the  band  is  then 
adjusted,  and  the  pelvis  buckled  to  the  floor,  after  which  it 
will  be  found  that  the  thighs  can  be  freely  flexed.  A  tripod 
is  now  erected  over  the  pelvis,  consisting  of  three  stiff  poles 
about  eight  feet  high,  and  held  together  at  the  top  by  a  coni- 

1  Apparatvis  for  angular  extension.  This  woodcut  represents  the  coni- 
cal leather  cap  and  rings,  the  angular  splint,  with  rings  above  and  below 
the  knee  for  the  passage  of  a  transverse  wooden  lever,  and  of  a  longitu- 
dinal one  beneath  the  calf,  the  padded  T  pelvis  band,  and  the  hooks  to 
attach  it  to  the  floor. 


116 


ANGULAR  EXTENSION. 


cal  leather  cap,  with  three  short,  dependent  straps  and  rings 
from  which  the  pulleys  are  suspended.     It  remains  only  to 

attach  the  pulleys  to 
the  limb.  This  is 
effected  by  means  of 
a  strong  right-angled 
splint  of  sheet-iron, 
extending  nearly  from 
the  hip  to  the  ankle, 
made  concave  so  as 
to  embrace  the  under 
surface  of  the  thigh 
and  leg,  and  padded, 
within  which  the  limb, 
flexed  at  right  angles, 
is  confined  by  ban- 
dages or  straps.  Two 
iron  rings  riveted  to 
the  splint  near  the 
condyles  of  the  femur 
receive  a  wooden  rod 
about  two  feet  in  length  and  an  inch  in  diameter,  which 
crosses  the  ligament  of  the  patella  transversely  above  the 
head  of  the  tibia ;  and  to  this  rod,  between  the  rings,  the 
pulleys  are  attached  by  a  strap  or  cord.  Vertical  traction 
is  thus  made  exactly  in  the  axis  of  the  shaft  of  the  femur. 

Powerful  rotation  can  be  made  by  grasping  the  extremities 
of  this  transverse  rod,  while  another  useful  movement,  called 
by  the  French  bascule,  or  tilt,  may  be  effected  by  a  similar 

1  Angular  extension.  The  pelvis  is  buckled  to  the  floor.  The  flexed 
leg  is  suspended  from  the  cap  at  the  summit  of  the  tripod  by  pul- 
leys which  are  attached  to  a  transverse  wooden  rod  across  the  patella. 
This  rod  passes  through  rings  on  the  angular  splint,  and  serves  to  rotate 
the  limb.     A  similar  rod  is  seen  beneath  the  leg. 


Fig.  44.1 


ANGULAR  EXTENSION.  II7 

rod  in  the  axis  of  the  leg  below  the  knee,  passed  through  two 
rings  beneath  the  splint,  —  one  near  the  ham,  the  other  near 
the  heel,  beyond  which  it  projects  a  foot  or  more,  —  to  afford 
a  handle.  By  vertically  raising  this  rod  at  its  extremity  we 
carry  the  head  of  the  bone  from  the  dorsum,  or  pubes,  in  the 
direction  of  the  tuberosity. 

Oblique  extension  may  be  made  by  changing  the  position  of 
the  tripod. 

Although  the  need  of  this  apparatus  may  be  rare,  it  will 
prove  occasionally  efficient  in  reducing  a  luxation  of  long- 
standing or  complicated  with  fracture.  At  any  rate,  I  can- 
not believe  that  the  period  is  remote  when  longitudinal 
extension  by  pulleys  to  reduce  a  recent  hip  luxation  will  be 
unheard  of. 


118  DISLOCATION  OF  THE  HIP. 


ON  DISLOCATION  OF   THE  HIP.i 

The  simplicity  of  the  principle  which  controls  hip  reduction 
is  as  yet  scarcely  appreciated  by  the  majority  of  practitioners 
into  whose  hands  the  scattered  cases  fall.  Writers  also,  until 
very  lately,  have  seemed  disposed  to  consider  "  manipulation  " 
as  but  one  of  several  means  of  reduction  of  equal  value, —  oc- 
casionally available,  indeed,  but  complicated  with  many  meth- 
ods, and  by  conflicting  opinions  regarding  its  essential  features, 
—  by  perplexing  talk  of  abduction  and  inversion,  of  flexion 
and  partial  flexion,  of  rotation  and  circumduction.  I  have, 
perhaps,  myself  unintentionally  contributed  to  this  erroneous 
belief.  But  my  paper  upon  this  subject  ^  was  based  upon  the 
analysis  of  a  large  number  of  dissections,  experiments,  and 
cases  of  reduction,  which  could  neither  be  condensed  advan- 
tageously nor  yet  omitted ;  while  its  object  was  to  show  the 
relation  between  hip  dislocation  and  the  ilio-femoral  ligament, 
then  generally  unrecognized.  The  whole  matter  is  really  very 
simple.  The  word  "  manipulation "  is  an  unfortunate  one  ; 
"flexion"  is  .better.  The  modern  method  of  hip  reduction, 
whether  by  lifting  or  by  mere  abduction,  is  the  "  flexion 
method ; "  and  it  supersedes  all  others. 

A  common  way  of  describing  dislocation  is  by  the  terms 
"  backward,"  "  forward,"  "  in  front,"  and  "  behind."  It  should 
be  borne  in  mind  that  when  the  body  is  erect  the  pelvis  is  ob- 
lique,—  the  acetabulum  standing  in  like  manner  obliquely,  at 
an  angle  of  about  45° ,  facing  the  front  and  outside  of  the  thigh, 
at  a  point  an  inch  or  two  below  the  trochanter ;  so  that  what 

1  The  Lancet,  June  15,  22,  29,  1878. 

2  The  Mechanism  of  Dislocation  and  Fractvu'e  of  the  Hip.  (Henry  C. 
Lea,  Philadelphia,  1869.) 


DISLOCATION   OF   THE   HIP.  119 

is  behind  the  socket  may  be  either  below  or  outside  of  it.  In 
fact,  it  is  not  easy  immediately  to  place  an  os  innominatum, 
or  even  a  pelvis,  in  the  normal  erect  attitude  to  which  alone 
these  terms  should  refer. 

As  preliminary  to  reduction,  the  patient  should  be  etherized 
to  relaxation,  and,  in  order  to  give  the  surgeon  control  of  the 
limb,  laid  on  the  floor.  It  is  well  to  remember  that  the  head 
of  the  femur  always  faces  the  same  way  as  the  internal 
condyle. 

If  there  is  any  single  and  best  rule  for  reducing  a  recent 
dislocation  of  the  hip,  it  is  to  get  the  head  of  the  femur 
directly  below  the  socket  by  flexing  the  thigh  at  about  a  right 
angle,  and  then  to  lift  or  jerk  it  forcibly  up  into  its  place. 
This  rule  applies  to  all  dislocations  except  the  pubic,  and  even 
to  that  when  secondary  from  below  the  socket.  I  have  taught 
it  many  years.  A  case  reduced  by  this  method  under  the 
care  of  the  distinguished  surgeon,  Mr.  Erichsen,  will  be  found 
in  "  The  Lancet "  for  1872  (vol.  i.  p.  10).  Of  the  various 
ways  which  incorporate  the  essential  principle,  this  one  was 
placed  first  in  my  paper  in  connection  with  the  common  dor- 
sal dislocation ;  and  I  elsewhere  showed  how  it  was  applicable 
to  other  dislocations.  The  reduction  by  the  lifting  method 
is  usually  instantaneous ;  and  flexion  is  at  the  basis  of  its 
success. 

But  if  after  one  or  two  trials  it  should  appear  that  the  hip 
cannot  be  jerked  into  place,  let  the  rent  in  the  capsule  be 
enlarged  a  little  by  moving  the  flexed  tliigh,  not  up  and  down, 
but  from  one  side  to  the  other,  so  as  to  sweep  the  head  of  the 
femur  across  below  the  socket.^     No  danger  need  be  appre- 

1  The  following  case  is  interesting  in  this  connection  :  A  short  and 
very  fat  elderly  woman  was  suspected  of  thyi'oid  dislocation.  Attempts 
already  made  to  reduce  the  bone  had  so  loosened  the  capsule  that  the 
limb  was  now  lying  parallel  with  the  other.  While  the  foot  could  be 
everted  or  inverted,  the  head  of  the  bone  could  be  nowhere  felt.     In 


120  DISLOCATION  OF  THE   HIP. 

hended  from  this  expedient  of  circumduction;  the  added 
injury  is  a  very  slight  one.  So  long  as  air  is  not  admitted 
to  the  wounded  parts  the  lesion  is  no  more  serious  than  often 
occurs  in  a  simple  fracture  of  the  thigh.  The  laceration 
which  resulted  from  the  old  longitudinal  traction  with  pulleys 
was  often  much  greater,  and  that  from  ill-planned  and  pro- 
tracted efforts  by  flexion  is  always  so.  Indeed,  such  addi- 
tional laceration  may  sometimes  advantageously  occur  without 
the  knowledge  of  the  surgeon  during  unsuccessful  efforts  to 
reduce  the  bone,  especially  in  executing  the  manoeuvre  de- 
scribed in  the  rule  "•  Flex,  abduct,  evert."  ^ 

consultation  I  was  quite  unable  to  satisfy  myself  about  the  lesion  until 
it  occurred  to  me  to  flex  the  limb  and  circumduct  the  head  of  the  bone, 
as  if  it  had  been  dislocated  upon  the  thyroid  foramen  to  the  dorsum. 
Then  the  characteristic  inversion  at  once  demonstrated  the  dislocation. 
The  thigh  was  again  brought  to  a  perpendicular,  and  readily  lifted  into 
place,  —  circumduction  here  affording  a  valuable  means  of  diagnosis  as 
well  as  of  reduction. 

1  Flexion  dates  from  Hippocrates.  He  combined  with  it  a  movement 
which,  by  a  literal  translation  of  the  original,  is  the  "  wagtail  shake  " 
((cty/cXio-t?).  (See  "The  Mechanism  of  Dislocation,"  etc.,  p. 27,  footnote). 
But  Hippocrates  seems  to  have  relied  mainly  on  direct  extension,  aided 
by  the  rude  application  of  levers  and  other  mechanical  expedients.  The 
method  concisely  expressed  in  the  words  "flex,  abduct,  evert,"  a  method 
the  paternity  of  which  has  sometimes  been  in  doubt,  belongs  to  an  in- 
vestigator of  fifty  years  ago,  a  man  of  highly  original  mind,  —  the  late 
Nathan  Smith,  Professor  of  Medicine  in  Dartmouth  College,  New  Hamp- 
shire, and  afterward  Surgical  Professor  in  Yale  College.  He  attended 
lectures  in  Edinburgh  under  the  elder  Monro  and  Dr.  Black,  and  studied 
also  in  London.  In  a  Biograj)hical  Memoir  published  in  1831,  soon  after 
his  death,  it  is  stated  that  "his  mode  of  reducing  dislocations  of  the 
hip  is  new,  philosophical,  and  ingenious."  In  a  posthumous  volume  of 
"Medical  and  Surgical  Memou-s"  (Baltimore,  printed  by  William  A. 
Francis,  18.31),  edited  by  his  son,  Nathan  R.  Smith,  M.D.,  twenty  pages 
are  devoted  to  a  detailed  description  of  his  method,  from  which  the  fol- 
lowing is  taken  (pp.  180,  181):  "  The  first  effort  which  the  operator  makes 
is  to  flex  the  leg  upon  the  thigh,  in  order  to  make  the  leg  a  lever  with 
which  he  may  operate  on  the  thigh-bone.  The  next  movement  is  a  gen. 
tie  rotation  of  the  thigh  outward,  by  inclining  the  foot  toward  the  ground 
and  rotating  the  knee  outward.     Next,  the  thigh  is  to  be  slightly  ab- 


DISLOCATION  OF  THE   HIP.  121 

This  familiar  rule,  until  I  explained  its  mechanism,  was  an 
empirical  one.  Flexion  is  indeed  the  essence  of  it ;  but  besides 
this,  the  femur  is  rotated  around  the  ilio-femoral  ligament  as 
a  centre.  When  the  knee,  abducted  by  this  rotation,  descends 
on  the  outside,  the  head  of  the  femur  rises  on  the  inside,  like 
an  opposite  spoke  in  the  wheel,  and  is  thus  pried  into  place 
by  the  shaft  of  the  bone  as  a  lever,  with  the  outer  band  of  the 
ligament  as  a  fulcrum.  Eversion  is  of  less  importance,  but 
helps  the  movement  by  inclining  the  head  of  the  abducted 
femur  toward  the  socket.  It  is  best  effected  by  keeping  the 
foot  of  the  flexed  limb  stationary  while  the  knee  is  pressed 
outward.  By  the  great  power  it  gives  the  operator,  this 
method,  or  rather  the  circumduction  connected  with  it,  is 
especially  useful  in  breaking  the  adhesions  of  an  old  dislo- 

ducted  by  pressing  the  knee  directly  outward.  Lastly,  the  surgeon  freely 
flexes  the  thigh  upon  the  pelvis  by  thrusting  the  knee  upward  toward  the 
face  of  the  patient,  and  at  the  same  moment  the  abduction  is  to  be 
increased.  Professor  N.  Smith  regarded  the  free  flexion  of  the  thigh 
upon  the  pelvis  as  a  very  important  part  of  the  compound  movement. 
He  believed  that  it  threw  the  head  of  the  bone  downward,  behind  the 
acetabulum,  where  the  margin  of  the  cup  is  less  prominent,  and  over 
which,  therefore,  the  adductor  muscles  would  drag  it  with  less  difficulty 
into  its  place.  The  operator  may  slightly  vary  these  movements  as 
he  increases  them,  so  as  to  give  some  degree  of  rocking  motion  to  the 
head  of  the  os  femoris,  which  will  thereby  be  disengaged  with  the  more 
facility  from  its  confined  situation  among  the  muscles."  This  covers 
the  ground  of  priority  of  invention.  It  belongs  to  Nathan  Smith.  But 
surgeons  were  not  as  yet  prepared  for  so  considerable  an  innovation. 
In  the  words  of  Professor  N.  R.  Smith  (p.  174),  "the  propriety  of  em- 
ploying pulleys,  for  the  purpose  of  multiplying  power  in  the  treatment 
of  dislocations  of  the  hip,  appears  to  be  so  tacitly  and  universally  ad- 
mitted at  the  present  time  that  one  who  contends  against  it  can  scarcely 
expect  to  obtain  a  favorable  hearing."  The  method  by  flexion  and 
abduction  had  been  taught  by  Nathan  Smith  long  before  1831.  In  1835 
Despres,  and  in  1852  Dr.  Reid,  of  Rochester,  N.  Y.,  enunciated  the  same 
views.  The  practice  was  good ;  but  both  Professor  Smith  and  Dr.  Reid 
based  the  method  and  sought  its  mechanism  in  the  erroneous  theory  of 
muscular  resistance.  The  rule,  it  should  be  added,  applies  only  to  dorsal 
dislocation. 


122  DISLOCATION  OF  THE  HIP. 

cation.  It  might  be  called  the  abduction  method,  to  distin- 
guish it  from  the  lifting  method. 

Abduction  sometimes  succeeds  at  once.  It  does  not  answer, 
however,  when  there  is  much  laceration  of  the  capsule.  Then 
the  head  of  the  bone  will  not  rise.  Suspended  by  the  ligament 
which  is  attached  at  the  trochanters,  it  slips  backward  and 
forward  below  the  socket,  from  the  dorsum  to  the  foramen 
ovale.  The  upward  lift  then  becomes  absolutely  essential.  In 
one  of  the  figures  of  a  standard  and  very  excellent  modern 
English  surgical  work,  which  has  done  me  the  honor  to  refer 
to  my  views,  the  engraver  has  placed  the  hand  of  the  surgeon 
above  the  knee,  adding  to  the  weight  of  the  limb,  and  bearing 
the  head  down  below  the  socket,  where  it  might  even  hook  up 
the  sciatic  nerve.  The  weight  of  the  limb  should  be  sustained 
with  the  hand  in  the  ham. 

Such  are  the  simple  principles  of  hip  reduction,  which  are 
still  often  buried  beneath  unimportant  details,  and  sometimes 
under  a  flood  of  technical  language. 

By  the  lifting  method  I  have  reduced,  without  haste,  a  dor- 
sal dislocation  of  both  hips  in  the  same  man  in  less  than 
two  minutes.  With  an  effort  to  do  it  quickly,  I  reduced  in 
two  seconds  a  dorsal  dislocation  that  had  just  been  vainly 
"  manipulated "  under  ether  by  two  medical  practitioners 
for  an  hour.  A  few  months  ago  I  forcibly  lifted  into  its 
place  from  the  dorsum,  in  a  few  seconds,  a  dislocated  hip, 
which  required  traction  with  the  whole  strength  of  the 
elbow  engaged  under  the  knee,  against  the  foot  upon  the 
pelvis. 

By  the  lifting  method  combined  with  abduction  I  have 
lately,  in  the  case  of  a  little  girl  of  seven  years,  reduced  a 
dorsal  dislocation  of  five  months'  standing,  said  to  have  oc- 
curred during  the  delirium  of  typhoid  fever.  To  keep  the 
bone  in  place  when  reduced  it  was  necessary  to  tie  the  knee 
to  the  side  of  the  bedstead,  in  extreme  abduction,  after  secur- 


DISLOCATION  OF  THE   HIP.  123 

ing  the  foot  to  the  knee  of  the  sound  side,  in  order  to  main- 
tain the  limb  in  the  final  position  that  reduced  it. 

Since  this  occurred  I  have  reduced  by  simple  abduction, 
and  in  a  moment,  a  recent  dorsal  dislocation  in  a  little  boy  of 
four  years. 

Prom  these  and  other  cases  may  be  gathered  the  following 
rules  for  reduction.     In  the  dorsal  dislocation, — 

1.  Flex,  and  forcibly  lift.     If  this  fails,  — 

2.  Flex,  and  lift  while  abducting.  If  this  fails,  it  will  be 
found  that  abduction  has  carried  tlie  head  of  the  bone  from 
the  dorsum  nearly  or  quite  to  the  thyroid  foramen,  and  that 
the  capsular  rent  has  been  so  enlarged  that  the  first  method 
may  now  prove  successful.  Lifting  the  femur  abducts  it  if  it 
raises  the  pelvis  on  the  lifted  side.  In  thyroid  dislocation 
adduction  of  the  flexed  thigh  reverses  this  movement  and 
carries  the  head  from  the  thyroid  foramen  to  the  dorsum, 
also  enlarging  the  opening  and  making  the  first  rule  effective. 
The  pubic  dislocations  may  be  generally  brought  down,  after 
flexion,  without  difiiculty  from  above  the  socket.  If  they  are 
secondary,  the  head  of  the  bone  will  fall,  after  flexion,  to  its 
previous  position  below  the  socket,  and  may  be  reduced  from 
there  like  the  thyroid. 

My  belief  has  long  been  expressed  that  the  flexion  method 
is  the  only  rational  one,  and  that  pulleys  are  practically  obso- 
lete, unless  perhaps  to  steady  the  limb  in  some  rare  case,  by 
rectangular,  not  longitudinal,  traction.  Then  alone  is  the  tri- 
pod apparatus  possibly  useful.  But  why  flex  the  thigh  ?  Be- 
cause it  relaxes  a  part  of  the  ilio-femoral  ligament.  When 
the  limb  is  straight,  this  ligament  is  rigid  and  the  bone 
fixed ;  when  it  is  flexed,  the  inner  band  is  slackened,  —  as 
also  the  whole  ligament  if  the  limb  be  lifted,  —  and  the 
head  is  brought  down  below  the  socket,  level  with  the  cap- 
sular rent,  becoming  movable  for  reduction  as  it  was  pre- 
viously for  escapa 


124  DISLOCATION  OF  THE   HIP. 

Now,  flexion,  with  adduction  or  abduction,  is  the  habitual 
attitude  of  the  thigh,  especially  in  action  or  for  self-defence  ; 
and  the  ligament  is  thus  habitually  relaxed.  On  this  account, 
and  also  because  the  capsule  is  weak  and  thin  below  "  like 
wet  bladder,"  and  the  socket  margin  notched  on  that  side,  the 
dislocation  downward  is  the  most  common  one.  All  this  I 
have  elsewhere  shown,  and  also  that  the  head  of  the  bone, 
thus  escaping  primarily  below  the  socket,  generally  at  once 
slides  up  to  a  second  position  on  one  side  of  it  or  the  other. 
In  fact,  downward  dislocation  is  so  frequent,  and  the  route 
from  below  to  the  dorsum  is  rendered  so  easy  both  by  mus- 
cular contraction  and  by  the  conformation  of  the  bone,  —  by 
the  latter  especially,  —  that  in  a  very  large  proportion  of  cases 
the  displacement  is  found  to  be  dorsal.  The  result  has  been 
to  extend  the  application  of  any  rule  for  reduction  which 
applies  to  dorsal  dislocation,  and  to  make  it  comparatively 
familiar. 

These  secondary  dislocations  from  below  the  socket  are  well 
known ;  and  all  the  regular  dislocations  (if  we  except  those 
between  the  small  rotator  muscles)  may  be  secondary.  On 
the  other  hand,  there  can  be  no  question  that  the  bone  may 
be  primarily  dislocated  in  various  directions.  Flexion  does 
not  in  all  dislocations  return  the  limb  to  a  point  below  the 
socket  without  increased  laceration  of  the  capsule,  as  it  would 
if  they  had  all  come  from  there.  Just  as  the  downward  dislo- 
cation may  take  place  during  extreme  flexion,  especially  with 
rotation  inward,  and  through  a  comparatively  small  aperture, 
so  the  dislocation  on  the  pubes  may  occur  during  extreme 
extension ;  and  it  is  usually  reduced  from  above  the  socket. 
A  direct  thrust  backward  may  produce  dislocation  upon  the 
dorsum  when  the  ilio-femoral  ligament  is  relaxed.  Primary 
dislocations  are  not  rare,  in  various  attitudes  of  the  limb. 

But  in  order  to  compare  the  regular  dislocations  more 
readily,  let  us  for  the  time  consider  them  all  as  secondary 


DISLOCATION   OF   THE   HIP.  125 

from  a  common  point  below  the  socket,  and  follow  the  pro- 
gress of  the  bone  from  the  moment  of  its  original  escape 
downward  to  this  point. 

The  femur  is,  then,  sometimes  held  below  the  socket  in 
extreme  flexion,  firmly,  as  if  the  neck  were  embraced  in  the 
capsular  rent.  Such  dislocations  have  been  considered  anom- 
alous, and  described  as  "  upon  the  perinajum,"  and  "  upon  the 
tuberosity."  I  have  shown  them  to  be  regular.  But  it  oftener 
happens  that  from  after-violence,  or  by  its  own  weight,  the 
knee  falls,  the  thigh  is  straightened,  and  the  head  of  the  bone, 
suspended  at  the  trochanters,  is  pried  upward  on  one  side  or 
the  other  of  the  socket,  lacerating  the  capsule.  In  this  view 
the  downward  dislocation  is  a  first  stage  of  the  others,  the 
head  pausing  below  the  socket  and  hesitating  which  side  to 
go,  —  whether  to  the  thyroid  foramen,  or  above  it  to  the  pubic 
region,  or  even  to  a  higher  point,  where  the  dislocation  is  still 
a  regular  one  (the  sub-spinous),  all  these  being  internal  to  the 
socket ;  or,  which  is  more  common,  external  to  and  behind 
the  socket  on  the  dorsum,  where,  as  I  have  shown,  the  limb 
is  at  once  inverted  by  the  outer  band  of  the  ilio-femoral  liga- 
ment. The  first  serious  obstacle  the  bone  then  encounters 
in  its  dorsal  ascent  is  the  strong  obturator  internus  muscle 
and  the  subjacent  capsule.  This  is  one  of  the  more  common 
dislocations.  If  the  bone  ruptures  the  obturator  and  the 
capsule,  it  rises  to  the  pyriformis,  and  if  this  be  broken,  to 
the  gluteus  minimus,  retaining  the  usual  features  of  a  dorsal 
displacement.^ 

If,  however,  the  outer  band  of  the  ligament  be  ruptured, 
the  limb  is  no  longer  necessarily  inverted,  but  capable  of 
eversion,  and  the  dislocation  is  then  the  everted  dorsal.  The 
head  of  the  bone,  still  suspended  by  the  remaining  inner 
band,  can  now  be  hooked  over  it  above  the  spinous  process ; 
the    dislocation   is   then  supra-spinous,  the   limb  being  still 

1  See  an  account  of  the  autopsy  in  Todd's  case,  No.  XL.  of  Cooper. 


126  DISLOCATION  OF  THE   HIP. 

straight.  But  if  the  femur  has  been  hooked  over  the  entire 
ligament,  instead  of  the  inner  band  only,  the  limb  cannot 
hang  straight ;  it  assumes  a  very  oblique  attitude  across  the 
axis  of  the  body.  This  I  have  called  the  anterior  oblique 
dislocation.  These  three  positions  of  the  bone  were  described 
by  Sir  Astley  Cooper  as  anomalous  ;  but  the  explanation  here 
given  of  their  essential  mechanism  shows  that  they  occur 
under  prescribed  conditions  of  the  ilio-femoral  ligament,  and 
that  they  are  therefore  constant  and  regular.  In  short,  all 
regular  dislocations,  including  those  upon  the  perineeum  and 
the  tuberosity,  as  well  as  the  everted  dorsal,  the  anterior- 
oblique,  and  the  supra-spinous  varieties,  have  constant  and 
distinctive  signs  which  they  owe  to  the  ilio-femoral  ligament ; 
and  eversion  in  dorsal  dislocation  signifies  that  the  outer  band 
of  this  ligament  has  been  severed. 

Nothing  can  be  more  simple  than  the  reduction  of  secondary 
dislocations  from  below  the  socket.  If  dorsal,  and  the  flexed 
thigh  has  fallen  to  a  horizontal  position  by  a  spiral  movement 
downward  and  inward,  reverse  the  movement  and  reduce  the 
limb  by  a  spiral  upward  and  outward.  If  thyroid  or  pubic, 
and  the  knee  has  followed  a  spiral  downward  and  outward, 
reduce  it  by  a  similar  movement  upward  and  inward.  But  the 
spirals  of  reduction  practically  amount  to  mere  flexion ;  there- 
fore, in  either  case,  flex  the  limb  and  jerk  it  upward ;  and  in 
the  thyroid  luxations  it  is  well  to  aid  the  process  by  outward 
traction  with  a  towel,  or  by  a  fulcrum  in  the  groin.  Finally, 
if  the  capsule  offer  resistance,  sweep  the  flexed  femur  from 
side  to  side  to  separate  its  fibres  and  get  the  head  below  the 
socket,  before  jerking  the  bone  up  into  place. 

There  is  another  point,  which  is  now  of  less  practical  im- 
portance. By  the  now  obsolete  straight  traction  with  pulleys 
reduction  from  the  dorsum  was  sometimes  difficult,  or  failed. 
Surgeons  then  called  the  dislocation  "  ischiatic."  There  was 
a  superstition  about  the  ischiatic  notch.     It  was  the  mael- 


DISLOCATION  OF  THE   HIP.  127 

strom  of  the  hip-bone.  There  was  obviously  in  those  days 
some  real  difficulty,  which  does  not  occur  with  the  flexion 
method.  Its  most  frequent  source  was  the  strong  obturator 
intcrnus  muscle  combined  with  an  unusually  sound  and 
tense  falciform  edge  of  the  subjacent  capsule,  interposed 
between  the  head  of  the  bone  and  the  socket,  occluding  the 
latter. 

On  this  account  I  substituted  for  the  term  "  ischiatic  "  the 
phrase  "  below  the  tendon,"  as  explanatory  of  the  manner 
of  the  displacement,  the  relations  of  the  bone,  and  the  general 
character  of  the  difficulty  of  its  reduction.  The  phrase 
"  below  the  tendon  "  was  desirable  to  distinguish  this  disloca- 
tion from  those  in  which  the  head  emerges  above  the  tendon. 
In  either  case  the  head  of  the  bone  may  reach  and  occupy  a 
place  "  behind  "  the  tendon  (see  "  The  Mechanism  of  Disloca- 
tion," etc.,  Fig.  15)  J 

When  my  paper  was  written,  the  bugbear  of  the  ischiatic 
notch  was  still  feared,  because  the  practice  of  reduction  by 
straight  extension  was  still  in  vogue.  In  fact,  surgical  works 
are  still  illustrated  with  pulleys  from  Sir  Astley  Cooper. 
For  more  than  fifteen  years  I  have  neither  employed  nor 
taught   reduction   by   straight   extension,   and    I   have   long 

1  The  dorsal  dislocation  between  the  small  rotator  muscles,  or  any 
other  which  offered  exce|)tional  resistance,  was  no  doubt  sometimes 
mistaken  for  the  "ischiatic"  dislocation.  I  still  incline  to  believe  that 
my  explanation  of  the  old  difficulty  in  "  ischiatic "  reduction  is  the 
correct  one.  The  dislocation  formerly  called  "  dorsal  "  differs  from  the 
"ischiatic"  in  having  the  thick  capsule  which  is  behind  the  ilio-femoral 
ligament  and  beneath  the  obturator  tendon,  including  the  ischio-femoral 
band,  so  torn  as  to  allow  a  greater  shortening  of  the  limb  than  used  to  be 
described  as  a  sign  of  "  ischiatic  "  displacement.  During  reduction  by 
straight  extension,  the  head  of  the  bone  could  pass  through  the  torn 
capsule  to  the  socket  as  soon  as  it  had  slipped  over  the  obturator  tendon. 
The  injury  may  be  accompanied  by  the  rupture  of  muscles,  even  of  the 
obturator  internus.  In  short,  the  classical  dorsal  and  ischiatic  disloca- 
tions differ  from  each  other  only  in  the  extent  of  the  laceration  of  the 
posterior  capsule  and  muscles. 


128  DISLOCATION   OF   THE   HIP. 

abandoned  any  especial  description  of  the  so-called  ischiatic 
dislocation,  whose  chief  and  distinctive  sign  was  that  it 
resisted  straight  extension.  For  practical  purposes  this  dis- 
location is  dorsal,  and  may  be  called  so.  It  is  easily  reduced 
by  flexion. 

So,  also,  it  is  useless  to  distinguish  from  the  common 
dorsal  dislocation  those  which  lie  between  the  small  rotators ; 
because,  although  interesting  to  the  anatomist  and  the 
pathologist,  it  is  very  doubtful  whether  they  will  ever  be 
diagnosticated  with  certainty  during  life.  They  exhibit,  as 
1  have  shown,  more  inversion,  more  immobility,  and  more 
elasticity ;  but  these  signs  are  not  pathognomonic.  When 
these  dislocations  occur,  the  head  of  the  bone  is  thrust  di- 
rectly backward  through  the  capsule,  and  escapes  this  time, 
not  below  the  tendon  of  the  strong  internal  obturator,  but 
above  it,  by  the  muscular  interstice  between  this  muscle  and 
the  pyriformis,  or  even  higher,  between  the  pyriformis  and 
the  gluteus  minimus.  The  bone  may  possibly  be  reduced 
from  these  positions  by  vertical  traction,  or  pried  back 
through  the  interstice  by  the  abduction  method  or  by  out- 
ward rotation ;  but  I  think  such  attempts  will  generally  end 
in  rupturing  the  muscles.  The  dislocation  would  then  offer 
no  distinctive  features,  and  would  belong  to  the  common 
dorsal  variety,  in  which  we  can  only  guess  what  rotators  are 
ruptured.  Indeed,  it  is  the  rule  in  dorsal  dislocation  that 
the  quadratus  or  some  of  the  rotators  are  torn,  —  which  of 
them  we  need  not  know.  Our  business  is  to  reduce  the 
bone  by  flexion,  —  and  by  circumduction  also,  if  that  be 
necessary  to  rupture  the  capsule  and  muscles,  and  so  to  clear 
the  way  to  a  point  below  the  socket,  from  which  the  femur 
can  be  lifted  into  place. 

If,  in  accordance  with  these  views,  we  suppress  any  distinct 
mention  of  the  inter-rotator  dislocations,  —  which  indeed  have 
never  been  separately  classified  (although,  if  it  were  possible 


DISLOCATION  OF  THE   HIP.  129 

always  to  identif}'  them,  they  would  deserve  to  be  separately 
considered),  —  and  of  the  obsolete  ischiatic  dislocation,  by 
whatever  name  we  call  it,  we  have  the  following  classifica- 
tion of  regular  dislocations,  based  on  their  direction  from 
the  socket :  — 

External  to  the  socket,  —  the  dorsal,  and  the  everted 
dorsal. 

Internal  to  the  socket,  —  on  the  perinaeum,  the  thyroid 
foramen,  and  the  pubes. 

Below  the  socket,  —  the  dislocation  toward  the  tuberosity. 

Above  the  socket,  —  the  sub-spinous,  the  supra-spinous,  and 
the  anterior  oblique  dislocations. 

Of  these,  by  far  the  more  common  are  the  dorsal,  the 
thyroid,  and  the  pubic,  which  offer  the  most  convenient 
division  for  practical  purposes.  It  leads  to  the  following 
practical  grouping  of  dislocations,  based  on  the  usual  me- 
chanism of  their  occurrence  and  of  their  reduction :  — 

Dorsal,  —  the  dislocation  on  the  tuberosity,  the  dorsal,  the 
everted  dorsal,  the  anterior  oblique,  and  the  supra-spinous. 

Thyroid,  —  that  on  the  perinaeum,  and  on  the  thyroid 
foramen. 

Pubic,  —  the  pubic  and  the  sub-spinous.^ 

The  ilio-femoral  ligament  is  unbroken  in  these  regular 
dislocations, —  excepting  only  the  everted  dorsal  and  supra- 
spinous varieties,  in  which  its  outer  band  is  severed,  while 
the  inner  band  remains.     All  may  be  readily  reduced  after 

1  This  is  perhaps  the  best  practical  classification.  Although  the  sub- 
spinous and  the  supra-spinous  dislocations  lie  directly  above  the  socket, 
the  former  is  essentially  a  pubic  dislocation,  and  after  flexion  needs  only 
to  be  worked  directly  down  into  the  socket.  The  supra-spinous  disloca- 
tion on  the  contrary,  like  the  anterior  oblique,  must  be  first  unhooked 
from  the  ligament,  and  then  circumducted  to  the  socket  by  the  way  of 
the  dorsum.  It  is  essentially  dorsal.  In  a  regular  dislocation  the  bone 
does  not  pass  the  ilio-femoral  ligament,  whether  it  approaches  it  from  the 
inside  or  the  outside. 


130  DISLOCATION  OF  THE  HIP. 

flexion,  with  or  without  circumduction,  —  the  thyroid  and 
pubic  ^yith  a  towel  or  fulcrum  in  the  groin  if  need  be,  in  the 
one  for  outward,  in  the  other  for  downward  and  outward 
traction.  This  method  covers  the  reduction  of  the  primary 
as  well  as  the  secondary  forms  of  luxation. 

It  may  here  be  added  that  a  broken  socket  makes  reduc- 
tion difficult  or  impossible ;  and  that  if  the  femur  tends  to 
escape  after  being  reduced,  the  flexed  thigh  should  be  ab- 
ducted down  to  the  bed,  and  confined  there  at  right  angles 
with  the  body,  to  take  advantage  of  the  tense  ilio-femoral 
ligament  in  holding  the  bone  in  place,  as  in  an  instance  be- 
fore mentioned. 

In  illustration  of  some  of  these  points,  let  me  cite  a  few 
cases. 

1.  The  classical  case.  No.  XLIII.  of  Cooper.  In  this  case, 
during  straight  thyroid  reduction,  the  knee  was  raised,  and 
the  ligament,  of  course,  relaxed.  The  head  of  the  bone  was 
thus  unintentionally  dropped  from  the  thyroid  foramen  to  a 
point  below  the  socket.  In  this  position  it  should  have  been 
jerked  up  into  place ;  but  unfortunately  the  limb  was  again 
straightened.  The  head  of  the  bone  rose,  this  time  not  to 
the  thyroid  foramen,  but  upon  the  dorsum,  where  it  was 
engaged  behind  the  close-fitting  capsule,  and  probably  the 
obturator  muscle.  From  this  position  it  could  not  after- 
ward be  drawn  by  straight  extension,  and  was  therefore  pro- 
nounced irreducible.  This  case  led  Sir  Astley  Cooper  to 
warn  surgeons  not  to  flex  the  thigh.  In  reality,  flexion  with 
an  upward  jerk  was  what  the  case  required. 

2.  The  similar  case  of  Lisfranc,^ — a  dorsal  dislocation, 
which  that  surgeon,  with  eight  assistants,  failed  for  an 
hour  to  reduce  by  straight  extension.  The  patient  then  col- 
lapsed, and   afterward   died.      The   autopsy  showed  a  state 

1  Malgaigne's  "Traite,"  etc.,  torn.  ii.  pp.  818-829.     Plate  XXVI. 


DISLOCATION   OF  THE   HIP.  131 

of  things  which  doubtless  existed  in  the  case  of  Cooper. 
The  neck  of  the  bone  was  closely  tied  by  the  capsule ;  the 
head  had  emerged  below  the  obturator  internus,  and  was  Ije- 
hind  it.     It  was  easily  reducible  by  flexion. 

3.  Parmentier's  case  of  dorsal  dislocation  between  the 
rotators.^  The  posterior  half  of  the  capsule  was  largely  torn. 
The  head  had  escaped  by  a  muscular  buttonhole  above  the 
internal  obturator,  between  that  muscle  and  the  pyriformis, 
which  is  next  it. 

4.  The  similar  case  of  Servier,  above  the  latter  muscle.^ 
Here  the  articular  capsule  was  completely  torn  behind,  the 
head  of  the  bone  having  escaped  by  the  "  posterior  notch 
of  the  acetabulum"  (beneath  the  tendon  of  the  pyrifor- 
mis), emerging  above  the  pyriformis,  which  closely  con- 
fined it. 

5.  The  case  of  Dr.  Fenner,  of  New  Orleans,  quoted  in  Pro- 
fessor Hamilton's  valuable  and  comprehensive  treatise  on 
"  Fractures  and  Dislocations."  ^  The  head  was  on  the 
dorsum.  The  limb  was  shortened  an  inch  and  a  half,  and 
the  toes  turned  inward.  The  capsule  was  torn  through 
one  half  its  extent.  Portions  of  the  obturator  externus, 
pyriformis,  and  gemelli  were  ruptured  and  lacerated. 
"  Dr.  Fenner  now  proceeded  to  cut  away  the  muscles ;  and 
when  all  the  external  muscles  about  the  joint  had  been 
removed,  the  thigh  could  not  be  brought  down.  The  iliacus 
internus  and  psoas  magnus  were  then  severed,  which  per- 
mitted it  to  descend  a  little,  but  the  head  could  not  be 
replaced ;  the  triceps  adductor  was  then  divided  without 
effect ;  the  ilio-femoral  ligament  was  found  tensely  stretched. 
All  the  muscles  between  the  pelvis  and  the  thighs  were  then 
severed,  and  still  it  was  impossible  to  reduce  the  dislocation ; 

1  Bulletin  de  la  Societe  Anatomique,  p.  176.     1850. 

2  Bulletin  de  la  Societe  de  Chirurgie,  p.  485.     1863. 

3  Fifth  edition,  p.  676. 


132  DISLOCATION  OF  THE  HIP. 

the  head  of  the  femur  could  not  be  forced  back  through  the 
rent  in  the  capsule  from  which  it  had  escaped,  and  it  was  not 
until  the  opening  was  enlarged  from  one  half  to  three  quarters 
of  an  inch  that  the  reduction  was  accomplished.  Dr.  Fenner 
infers  that  the  capsule  possesses  sufficient  elasticity  to  allow 
the  small  head  of  the  femur  to  pass  out  through  a  lacerated 
opening,  which  might  at  once  contract  so  as  to  offer  con- 
siderable resistance  to  its  return,  and  that  occasionally  this  is 
the  true  explanation  of  the  difficulty  in  reduction."  Although 
the  existence  of  this  degree  of  elasticity  may  be  questioned, 
there  can  be  no  doubt  that  a  close-fitting  rent  in  the  capsule  is 
practically  a  "  buttonhole,"  whether  in  the  straight  or  flexed 
limb. 

Among  the  details  of  these  few  cases  will  be  found  evidence 
of  the  efficacy  of  the  flexion  method,  of  its  mode  of  action, 
and  of  the  character  of  a  difficulty  which  was  sometimes 
insuperable  by  the  old  method  of  straight  extension.  They 
show  that  this  difficulty  may  result  from  the  interposition  of 
capsule  or  muscle,  or  both,  between  the  head  of  the  bone  and 
the  socket,  —  or  from  a  want  of  free  aperture  in  the  capsule  ; 
and  that  then  the  obvious  resource  of  the  surgeon  is  to  enlarge 
the  slit  by  circumduction.  They  show  also  the  character  of 
the  intermuscular  aperture  between  the  rotators,  which  may 
require  similar  enlargement ;  and  that  it  may  sometimes  be 
difficult  to  distinguish  between  these  different  impediments  to 
reduction,  —  all  of  which  yield  to  flexion,  with  circumduction 
if  needed.  All  this  is  of  the  first  interest  to  the  surgeon, 
because  it  bears  upon  the  question  of  reduction.  The  cases 
also  contain  evidence  upon  one  or  two  points  of  minor  interest 
and  importance  ;  namely,  that  dislocation  may  occur,  not  only 
with  abduction  as  an  element,  as  writers  agree,  but  also  by  a 
direct  thrust ;  and  that  in  this  case  the  socket  need  not  be 
broken,  as  has  been  alleged. 

Upon  the  ilio-femoral  ligament  I  have  based  my  theory  of 


DISLOCATION  OF  THE   HIP.  133 

hip  dislocation,  its  classification,  its  mechanism  and  its  re- 
duction. Other  bands  of  fascia,  of  capsule,  and  of  muscle 
may  indeed  be  incidentally  concerned  in  confining  the  neck 
of  the  femur  ;  but  their  action  is  a  changing  one,  and  second- 
ary in  importance.  Divide  the  ilio-femoral  ligament,  leaving 
the  rest  of  the  tissues,  and  the  mainstay  of  the  characteristic 
deformity  is  gone.  It  is  not  difficult,  indeed,  still  to  work 
the  limb  into  the  semblance  of  a  regular  dislocation ;  but  such 
displacements  are  exceptional,  and  their  attitude  is  not  con- 
stant.    In  short,  they  are  irregular. 

All  that  is  most  essential  about  hip  dislocation  and  re- 
duction may  be  learned  from  a  pelvis  and  thigh-bone  from 
which  everything  has  been  removed  except  the  ilio-femoral 
ligament,  with  perhaps  the  obturator  internus  muscle  and 
its  subjacent  capsule,  although  the  last  two  can  be  spared. 

The  dissected  capsule  is  a  combination  of  membrane  with 
fasciculi  beautifully  adjusted  for  universal  motion,  limited 
in  all  directions.  The  vessel-bearing  and  so  called  "  liga- 
mentum  "  teres  within  it  is  never  strong,  and  is  sometimes 
wanting;  it  is  therefore  unimportant  in  dislocation.  Of  the 
capsule  itself  the  posterior  part  combines  strength  with  great 
mobility,  its  pelvic  insertion  being  far  stronger  than  its 
femoral  insertion.  A  general  notion  of  the  arrangement  of 
the  posterior  part  of  the  capsule  may  be  had  if  we  suppose 
that  it  is  extended  from  the  socket  half  way  to  the  femur, 
being  there  reinforced  by  a  thickened  edge  and  tied  to  the 
trochanters  by  bands.  The  thick  edge  is  represented  by  a 
fasciculus  which  is  said  to  be  "  annular."  It  is  parallel  with 
the  rim  of  the  acetabulum,  and  midway  of  the  capsule.  It 
aids  the  pelvic  half  of  the  capsule  in  its  effort  to  retain  the 
head  of  the  femur,  and  in  the  extended  limb  tightens  it. 
It  is  tied  to  the  trochanters  by  the  ischio  and  pubo  (or 
pectineo)  femoral  bands,  which,  as  they  pass  from  the  pelvis 
to  the  trochanters,  cross  the  annular  ligament  and  are  incor- 


134  DISLOCATION  OF  THE  HIP. 

porated  with  it.^  In  these  cross-bands  lies  the  main  strength 
of  the  femoral  insertion  of  the  posterior  capsule.  Between 
them,  at  a  point  between  the  trochanters,  is  its  weakest 
part, —  a  mere  membrane,  supported  bj^  these  fasciculi.  It  is 
often  accidentally  opened  in  dissection ;  and  when  torn  along 
its  margin,  as  sometimes  happens  in  dislocation,  after  the 
bands  are  ruptured,  the  wide  flap  may  occlude  the  socket  as 
eifectually  as  in  Fenner's  case. 

But  among  these  minor  anatomical  details  connected  with 
the  posterior  capsule,  it  is  important  not  to  lose  sight  of  the 
main  surgical  facts.  To  these  facts  the  ilio-femoral  ligament 
is  the  key.  It  lies  mostly  in  front.  In  an  anterior  view  it  is 
triangular,  narrowest  above.  Its  inner  part,  the  ligament  of 
Bertin,  limits  extension  of  the  limb ;  its  outer  part  limits 
eversion,  while  to  the  latter  alone  belongs  the  inversion  of 
dorsal  dislocation.  The  functions  of  its  outer  and  inner  por- 
tions are  therefore  largely  distinct.  The  habitual  action  of 
the  thigh  tends  to  develop  them  separately.  In  fact,  they 
can  be  easily  distinguished  by  the  direction  of  their  fibres, 
some  of  the  fibres  of  one  branch  being  inserted  into  the 
other  half  way  up.  They  are  separated  by  a  cribriform  in- 
terval for  vessels,  corresponding  to  a  frgenum  of  soft  capsule 
inside  the  joint,  which  adds  to  the  thickness  though  little  to 
the  strength  of  the  ligament.  They  vary  in  development  in 
different  subjects  ;  the  outer  band  is  not  unfrequently  the 
more  voluminous,  and,  as  is  stated  in  my  paper,  the  whole 
ligament  is  sometimes  of  uniform  thickness.  In  that  case 
its  margin  acts  as  bands. 

^  The  pubo  and  ischio  femoral  bands  are  best  seen  in  extreme  flexion, 
which  in  the  recumbent  subject  brings  the  back  and  lower  part  of  the 
capsule  to  the  front,  with  the  lesser  trochanter  above.  Parallel  lines 
then  drawn  from  points  on  the  pubes  and  the  ischium,  just  above  the 
socket  and  just  below  it,  horizontally  outward  to  the  two  trochanters 
respectively,  will  sufficiently  indicate  the  two  fasciculi,  and  the  rec- 
tangular shape  of  the  posterior  capsule  they  enclose.  In  the  extended 
limb  they  become  oblique,  and  are  no  longer  parallel. 


DISLOCATION  OF  THE   HIP.  135 

In  recent  times  the  narrow  ligament  of  Bertin  has  been 
generally  described  and  recognized  as  the  ilio-femoral  liga- 
ment. It  is  but  the  inner  part  of  it.  Its  outer  band  and 
even  its  triangular  shape  were  scarcely  known  to  modern 
anatomists,  and  were  unknown  in  their  surgical  application 
to  dislocsttion  when  I  came  across  them  in  dissection.^  I 
afterward  found  that  while  the  Webers  describe  the  liga- 
ment as  simply  triangular,  the  anatomist  Winslow,  and  es- 
pecially Weitbrecht,  —  still  perhaps  the  highest  authority  on 
ligaments,  —  had  described  the  "  binae  divaricationes"  a  cen- 
tury  and  more  ago.  Thus  much  for  the  lower  and  sometimes 
distinctly  forked  insertion  of  the  ilio-femoral  ligament  along 
the  anterior  intertrochanteric  line  of  the  femur. 

The  upper  or  pelvic  insertion  of  this  ligament  is  into  the 
front  of  the  inferior  spinous  process  of  the  ilium,  and  also 
into  the  outside  of  this  process,  along  a  rough  depression 
existing  beneath  the  reflected  tendon  of  the  rectus,  three- 
quarters  of  an  inch  or  more  in  length.^  All  this  part  is 
thick,  and  arrests  displacement  directly  upward.  From  this 
pelvic  insertion  the  outer  margin  of  the  outer  band  runs  to 
the  trochanter  major,  and  the  inner  margin  of  the  inner 
band  toward  the  trochanter  minor.  Together  the  two  bands 
constitute  the  strongest  ligament  in  the  body.  While  it  is 
not  difficult  by  circumduction  to  tear  the  whole  capsule  on 

1  The  only  modern  anatomy  in  which  I  find  an  allusion  to  the  fan- 
shaped  outline  of  the  ilio-femoral  ligament  is  that  of  Sappey,  Paris, 
second  edition,  1867.  The  first  edition  (1862)  figures  and  describes 
only  the  ligament  of  Bertin.  My  photograph  was  taken  in  1861  and 
published  in  1869. 

2  This  roughened  surface,  extending  from  the  inferior  spinous  pro- 
cess outward,  and  in  the  normal  oblique  attitude  of  the  pelvis  a  little 
upward,  has  been  sometimes  assigned  by  anatomists  to  the  reflected 
tendon  of  the  rectus.  It  belongs  to  the  wide  outside  insertion  of  the 
powerful  ilio-femoral  ligament,  to  which  the  tendon  is  often  attached 
by  connective  tissue  only,  having  a  comparatively  small  bony  insertion 
beyond  it. 


136  DISLOCATION  OF  THE  HIP. 

either  side  up  to  the  margin  of  the  bands,  these  resist.  In 
a  strictly  surgical  point  of  view,  the  exact  extent  of  their 
varying  interval  may  have  little  importance ;  but  in  order 
to  emphasize  their  separate  normal  functions,  and  especially 
the  fact  that  the  characteristic  attitudes,  the  mechanism, 
and  the  reduction  of  hip  dislocation  are  essentially  dependent 
semetimes  upon  one  of  these  sets  of  fibres  and  sometimes 
upon  the  other,  I  have  given  to  the  whole  —  as  brief,  and  sug- 
gestive of  its  "  binse  divaricationes  "  —  the  name  (inverted) 
Y  ligament. 


THE  MECHANISM  OF  FRACTURES  OF 
THE  NECK  OF  THE  FEMUR. 


FEACTURE  OF  THE  NECK  OP 
THE  FEMUR. 


IMPACTED  FRACTURE  OF  THE  BASE  OF  THE  NECK,  WITH  EVERSION. 

The  injury  known  as  the  "  impacted  fracture  of  the  neck  of 
the  thigh-bone  "  has  been  well  described  by  various  writers. 
When  it  occurs,  the  neck,  broken  at  or  near  its  broad  inser- 
tion into  the  head  of  the  shaft,  is  driven  into  the  loose  cancel- 
lated tissue  of  the  latter,  and  so  fixed  there  that  it  sometimes 
requires  a  considerable  force  to  withdraw  it.  That  it  may  be 
a  severe  lesion,  especially  in  the  latter  part  of  life,  the  numer- 
ous recent  specimens  to  be  found  in  museums  sufficiently 
attest.  In  my  own  observation,  while  it  is  at  least  as  frequent 
among  elderly  people  as  fracture  of  the  neck  within  the  cap- 
sule without  impaction,  the  accident  is  comparatively  common 
in  middle  life,  and  even  later;  and  the  bone  is  sometimes  capa- 
ble of  uniting  after  a  few  months,  with  little  deformity. 

This  fracture  is  characterized  by  shortening  and  eversion 
of  the  limb,  sometimes  so  inconsiderable  that  we  are  obliged 
to  accept  a  diagnosis  based  upon  an  almost  imperceptible 
eversion,  and  a  shortening  of  half  an  inch  or  less,  by  careful 
measurement. 

The  Museum  of  the  Medical  School  of  Harvard  University 
contains  a  valuable  collection  of  impacted  fractures  of  the 
hip ;  and  having  through  these  specimens  become  familiar 
with  the  eversion  exhibited  by  them  in  various  degrees,  I 
had  my  attention  more  carefully  directed  to  the  subject  by 
the  followinsr   not  unusual  case. 


140      FRACTURE  OF  THE  NECK  OF  THE  FEMUR. 

A  gentleman  slipped  upon  the  ice  before  his  door,  and  fell 
upon  his  hip.  He  walked  up  stairs  with  assistance,  and  was 
placed  upon  his  bed.  His  attending  physician,  in  the  absence 
of  any  obvious  shortening  or  eversion  of  the  limb,  entertained 
some  doubt  in  regard  to  the  nature  of  the  injury,  but  after  ten 
days,  finding  no  improvement  in  the  symptoms,  —  the  pain 
and  soreness  having  in  fact  increased,  —  requested  me  to  see 
him.  The  local  tenderness  and  pain  on  motion,  together 
with  a  very  slight  eversion,  —  best  seen  on  attempting  to 
invert  comparatively  the  two  feet,  —  and  a  shortening  of  less 
than  half  an  inch,  led  me  to  the  conviction  that  the  bone  was 
slightly  impacted  ;  and  I  conceive  this  view  to  have  been  cor- 
roborated by  callus  subsequently  felt  about  the  trochanter, 
and  by  the  length  of  time  required  for  the  recovery,  —  the 
patient  having  been  confined  to  his  bed  a  little  more  than 
two  months,  and  unable  to  walk  without  crutches  until  after 
the  lapse  of  four  months. 

Since  that  time  I  have  had  sufficient  opportunities  to  satisfy 
myself  that  though  this  accident  may  be  serious  when  it 
occurs  late  in  life,  it  is  by  no  means  so  to  a  middle-aged  and 
healthy  subject ;  that  the  impaction  is  sometimes  slight,  and 
its  indications  proportionably  so ;  and  that  the  following 
signs  may  be  relied  on  as  generally  pathognomonic,  —  disabil- 
ity ;  pain  and  tenderness  resulting  from  local  violence,  es- 
pecially when  applied  laterally,  as  in  a  fall  upon  the  hip ; 
shortening  and  eversion,  however  slight ;  absence  of  crepi- 
tus ;  and  lastly,  the  rotation  of  the  trochanter  through  an 
arc  of  a  circle  of  which  the  head  of  the  bone  is  the  centre, 
instead  of  upon  the  axis  of  the  shaft,  as  in  detached  fracture 
of  the  neck. 

The  practical  importance  of  readily  identifying  this  fracture 
lies  in  the  fact  that  its  progress,  as  regards  both  time  and 
good  union,  is  in  general  more  favorable  than  that  of  the 
unimpacted    fractures ;    that   though   it   is   a   comparatively 


FRACTURE   OF   THE   NECK   OF   THE   FEMUR. 


141 


common  and  disabling  accident,  it  may  exhibit  little  deform- 
ity ;  and  lastly,  that  the  object  of  extension  in  its  treatment 
is  to  steady  the  limb,  and  not  to  draw  it  down. 

The  followmg  details  of  the  ana- 
tomical structure  of  the  femur  sus- 
tain the  foregoing  statements  in 
respect  to  the  shortening  and  ever- 
sion  incident  to  this  lesion. 


ANATOMICAL   STRUCTURE   OF   THE 
NECK   OF   THE   FEMUR. 

Let  a  well-developed  femur  be 
placed  in  a  vice  with  its  back  toward 
the  observer,  in  its  natural  upright 
position,  but  obliquely,  as  if  the  legs 
were  widely  separated,  the  shaft  be- 
ing so  far  inclined  that  the  neck  is 
horizontal.  Let  a  first  slice  be  now 
removed  from  the  top  of  the  head, 
neck,  and  trochanter  by  a  saw  car- 
ried horizontally  through  the  neck. 
Let  a  second  and  third  slice  be  re- 
moved in  the  same  way,  so  that  the 
neck  shall  be  divided  into  four  hori- 
zontal slices  of  equal  thickness.^ 

It  will  be  found  that  the  upper  section  exhibits  the  anterior 
and  posterior  walls  of  nearly  equal  thickness ;  but  that  as  we 

1  If  the  head  of  the  bone  be  now  vertically  transfixed  by  a  wire,  the 
sections  may  be  spread  for  examination  like  a  fan. 

2  Fig.  1  exhibits  a  bird's-eye  view  of  a  horizontal  section  of  the  neck 
of  the  femur,  showing  the  posterior  wall  plunging  beneath  the  inter- 
trochanteric ridge,  at  the  angle  where  the  neck  joins  the  shaft.  The 
posterior  wall  is  of  the  thinness  of  paper,  and  here  impaction  occurs.  The 
anterior  wall,  on  the  contrary,  is  seen  to  be  quite  thick,  and  forms  by  its 
fracture  a  hinge  which  is  very  rarely  impacted. 


Fig.  1.2 


142 


FRACTURE  OF  THE  NECK  OF  THE  FEMUR. 


Fig.  2.1 


approach  the   lower  surface   of  the  neck  the  anterior  wall 
becomes  of  great  thickness  and  strength,  while  the  posterior 

wall  remains  thin,  especially  at  its 
insertion  beneath  the  posterior  in- 
tertrochanteric ridge,  where  it  is  of 
the  thinness  of  paper. 


ROTATION. 

The  result  of  this  conformation 
is  obvious.  In  impacted  fracture, 
the  thin  posterior  wall  is  alone 
impacted,  while  the  thick  anterior 
wall,  refusing  to  be  driven  in,  yields 
only  as  a  hinge  upon  which  the 
shaft  rotates  to  allow  the  posterior 
impaction.  This  phenomenon,  varying  a  little  with  the  injury, 
is  constant  in  every  specimen  of  simple  impacted  fracture  I 
have  examined ;  and  in  fact  it  must  be  so  from  the  arrange- 
ment of  the  bony  tissues,  which  at  once  invites  and  explains 
the  eversion.2 

SHORTENING. 

The  hinge  before  alluded  to  is  oblique,  following  the  ante- 
rior intertrochanteric  line.     Were  it  vertical,  by  bending  this 

1  The  same  as  Fig.  1.  The  section  of  tlie  shaft  near  the  lesser  tro- 
chanter shows  the  lower  extremity  of  the  septum,  where  the  wall  is 
thicker  and  changes  its  direction.     (From  a  photograph  taken  in  1861.) 

2  M.  Robert,  in  a  memoir  upon  impacted  fractures  of  the  neck  of  the 
fenim",  attributes  the  posterior  impaction  to  the  supposed  fact  that  the 
tangential  plane  of  the  external  surface  of  the  trochanter  is  inclined 
obliquely  backward  to  the  axis  of  the  neck,  and  that  a  force  applied  to 
its  centre  would  tend  to  increase  the  obliquity  of  this  angle,  and  thus  to 
produce  outward  rotation  of  the  shaft.  The  shortening  of  the  limb  he 
attributes  to  the  fact  that  the  impaction  is  greatest  at  its  lowest  part. 
(IVIemoire  sur  les  Fractures  du  Col  du  Femur  accompagnees  de  Penetra- 
tion dans  le  Tissu  Spongieux  du  Trochanter.  Par  Alphonse  Robert,  Prof es- 
seur  Agrege,  etc.     Memoires  de  I'Academie  de  Medecine,  torn.  xiii.  p.  487.) 


FEACTUEE   OF  THE   NECK  OF   THE   FEMUE.  143 

hinge  we  should  produce  rotation  without  shortening.  On  the 
other  hand,  if  it  were  horizontal  and  transverse,  bending  it 
would  produce  shortening  without  rotation  ;  but  as  it  stands 
at  an  angle  of  45°,  the  shaft  rotating  upon  this  broken  inter- 
val is  shortened  in  proportion  to  its  rotation,  —  or,  what  is 
the  same  thing,  the  neck  is  reflected  upon  its  hinge  downward 
and  backward  till  its  axis  normally  oblique  may  become  even 
transverse,  with  great  outward  rotation  of  the  shaft  and  a 
shortening  of  perhaps  two  inches.  This  is  probably  the  most 
common  cause  of  shortening,  although  the  head  of  the  bone 
may  be  otherwise  depressed.^ 

TRUE    NECK. 

Upon  examining  the  lower  of  the  above  sections  in  a  well- 
marked  bone,  the  posterior  or  papery  wall  of  the  neck  will  be 
seen  to  be  prolonged  by  radiating  plates  into  the  cancellous 
structure  beneath  the  intertrochanteric  ridge.  That  the  thick- 
est of  these  (Fig.  1)  is  a  continuation  of  the  true  neck  may  be 
shown  in  another  way.  Let  the  whole  of  the  posterior  inter- 
trochanteric ridge,  including  the  back  part  of  both  trochanters, 
be  removed  by  a  narrow,  thin  saw.  (Fig.  3.)  The  bone 
being  now  laid  upon  a  table,  let  a  chisel,  or  what  is  better  a 
gouge,  be  held  perpendicularly  upon  the  cancellous  structure 
thus  exposed,  and  lightly  twirled  until  the  friable  and  spongy 
tissue  is  removed  and  the  instrument  arrested  by  the  septum, 
or  wall,  alluded  to.  To  expose  its  inner  surface,  the  shaft 
should  be  split  by  a  vertical  and  curved  section  behind  this 
wall,  and  the  cancellous  structure  removed  in  the  same  way. 

The  septum  will  then  be  distinctly  seen  as  a  thin,  dense  plate 
of  bone  continuous  with  the  back  of  the  neck  and  reinforcing 
it,  plunging  beneath  the  intertrochanteric  ridge  in  an  endeavor 
to  reach  the  opposite  and  outer  side  of  the  shaft.     At  its  lower 

1  See  pp.  157,  161,  163. 


144 


FRACTURE  OF  THE  NECK  OF  THE  FEMUR. 


extremity  it  curves  a  little  forward,  so  as  to  take  its  origin 
when  on  a  level  with  the  lesser  trochanter  from  the  centre, 
instead  of  the  back,  of  the  cylindrical  cavity,  —  a  disposition 
easily  seen  in  a  transverse  section  of  the  shaft  just  above  the 
trochanter  minor.  (Fig.  2.)  Or  it  may  be  said  that  the 
posterior  wall  of  the  neck  forks  before  reaching  the  intertro- 
chanteric line,  one  layer  being  seen  upon  the  surface,  while 
the  other  dives  beneath  the  intertrochanteric  ridge  in  a  vain 


""       W«i'Nl.ll'«l||| 
Fig.  3.1 

attempt  to  reach  the  outer  wall  of  the  shaft.  If  these  views  be 
correct,  the  intertrochanteric  ridge  is  simply  a  buttress  erected 
for  the  insertion  of  muscles  upon  and  over  the  true  neck,  by 
the  impaction  of  which  it  is  in  fact  often  split  off  and  detached 
in  a  mass, — the  force  exerted  by  the  true  neck,  though  slight, 
being  nevertheless  an  effort  to  resist  such  impaction. 


1  Anatomy  of  impacted  fracture.  The  intertrochanteric  ridge  has 
been  removed,  and  the  cancellous  structure  so  excavated  as  to  exhibit  the 
true  neck  beneath.  The  rod  is  placed  in  a  longitudinal  fissure  by  which 
the  shaft  of  the  bone  has  been  split,  in  order  to  exhibit  the  true  neck  from 
within.     (From  a  photograph  taken  in  1861.) 


FRACTUKE   OF  THE   NECK   OF  THE   FEMUR.  145 

REMAEKS. 

Surgical  writers  have  been  at  some  pains  to  indicate  the 
distinguishing  marks  and  tendencies  of  the  so-called  fractures 
"within"  and  "without  the  capsular  ligament,"  —  names 
which  have  but  little  practical  significance.  While  the  im- 
pacted fracture  of  the  base  of  the  femoral  neck  unites  by  bone, 
if  at  all,  there  seems  to  be  a  decreasing  tendency  to  osseous 
union  as  we  approach  the  smaller  portion  of  the  neck  near  its 
head,  —  a  circumstance  probably  due  in  part  to  the  feeble  nu- 
trition of  the  detached  extremity,  and  in  part  to  its  mobility. 
The  fact,  which  Sir  Astley  Cooper  did  not  deny,  that  bony 
union  is  possible  "  witbin  the  capsular  ligament "  ^  and  at 
the  slenderer  portions  of  the  neck,  is  now  sufficiently  attested 
by  existing  specimens,  our  University  Museum  possessing  two 
of  these.  But  in  examining  specimens  of  such  bony  union  it 
is  often  difficult  to  say  just  how  far  the  fracture  was  originally 
within  or  without  the  capsule,  because  the  exact  position  and 
limit  of  the  capsule  itself  are  variable  ;  ^  and  if  we  except  the 
impacted  fracture  at  the  base,  it  is  impossible  during  life,  by 
any  justifiable  examination,  to  decide  what  part  of  the  neck  is 
broken,  or  whether  the  fracture  has  occurred  within  or  without 
the  capsule.  Nor  is  it  a  matter  of  importance  in  the  treat- 
ment, which  is  one  and  the  same  in  both  cases,  or  in  prog- 
nosis, if  the  so-called  varieties  cannot  be  distinguished.  In 
lecturing  upon  this  subject,  I  have  been  in  the  habit  of  divid- 
ing the  injuries  of  the  neck  of  the  femur  into  the  impacted 
fracture  of  the  base  of  the  neck  and  the  unimpacted  fracture 
of  the  rest  of  the  neck,  without  regard  to  the  capsule,  —  a 
practical  classification  embracing  a  majority  of  cases,  and  to 
which  the  other  lesions  may  be  regarded  as  exceptional. 

1  Treatise,  etc.,  pp.  137,  138. 

2  The  Insertion  of  the  Capsular  Ligament  of  the  Hip-Joint,  and  its 
Relation  to  Intra-Capsiilar  Fracture.  By  George  K.  Smith,  M.D.,  Demon- 
strator of  Anatomy,  etc.     New  York,  1862. 

10 


146      FRACTURE  OF  THE  NECK  OF  THE  FEMUR. 

It  is  indeed  possible  for  the  small  extremity  of  the  neck  to 
be  impacted  into  the  detached  head,  and  so  steadied  by  it  as 
to  favor  union.  Such  was  the  injury  in  the  specimens  in 
our  Museum  described  below.  It  is  also  possible  for  the  base 
of  the  neck  to  be  impacted  with  inversion ;  but  in  the  large 
majority  of  cases,  if  there  is  a  serious  injury  to  the  neck 
of  the  bone,  it  is  either  a  common  impacted  fracture  of  the 
base  of  the  neck,  easily  diagnosticated  by  the  signs  already 
described,  or  some  other  fracture,  about  which  it  is  of  no 
practical  consequence  in  its  treatment  to  know  anything, 
except  that  it  exists  and  needs  .extension. 

In  brief,  the  presence  of  excessive  pain  on  motion  leads  to 
the  suspicion  of  sevei^  injury.  The  age  of  the  patient ;  the 
shortened,  everted,  loosely  hanging,  and  uncontrollable  limb; 
crepitus,  which  when  once  felt  is  as  satisfactory  as  if  felt,  to 
the  detriment  of  the  patient,  many  times,  —  and,  lastly,  the 
head  of  the  trochanter  rotating  on  the  axis  of  the  shaft  and 
not  through  an  arc,  readily  and  quickly  identify  the  unim- 
pacted  fracture.  On  the  other  hand,  the  impacted  fracture 
of  the  base,  which  occurs  in  the  adult  at  all  ages,  though 
more  frequently  in  the  latter  half  of  life,  is  characterized  by 
less  local  pain  and  disability,  by  shortening  and  eversion^ 
(which  may  be  slight),  and  by  the  absence  of  crepitus,  while 
the  trochanter  rotates  through  an  arc  upon  the  articulation 
as  a  centre. 

The  importance  of  distinguishing  between  the  different  frac- 
tures of  the  neck  of  the  femur  is  not  so  great  as  to  justify  any 
protracted  or  considerable  examination.  Flexion  of  the  thigh, 
its  repeated  rotation,  or  other  unscrupulous  or  unskilful  hand- 
ling, is  liable  to  lacerate  the  remaining  capsule,  to  displace  the 
bony  fragments,  or,  by  loosening  and  detaching  an  impacted 
fracture,  to  render  its  union  more  difficult,  —  adding,  perhaps, 

^  As  before  stated,  a  slight  eversion  is  perhaps  best  indicated  by  a 
comparison  of  the  extent  to  which  the  two  limbs  can  be  inverted. 


FRACTURE   OF  THE   NECK  OF  THE   FEMUR.  147 

to  the  accuracy  of  the  diagnosis,  but  directly  diminishing  the 
chances  of  the  patient. 

The  treatment  of  all  these  fractures  is  similar,  —  the  unim- 
pacted  fracture  obviously  requiring  extension,  the  purpose  of 
which  in  the  impacted  fracture  is  to  steady,  not  to  elongate, 
the  limb.  Among  the  many  expedients  presented  to  the  choice 
of  the  surgeon,  I  have  for  my  own  part  found  as  good  results, 
even  in  bad  cases,  from  a  flat  bed,  with  a  book  or  other  weight 
attached  to  the  foot  for  extension,  and  perhaps  a  broad  band 
about  the  hips  to  steady  the  parts,  and  a  cushion  or  pillow 
under  the  broken  hip  to  prevent  its  eversion,  as  from  more 
complicated  and  less  comfortable  apparatus.  The  prognosis 
of  these  fractures  it  is  difficult  to  give.  Elderly  people  may 
die  of  them  at  the  end  of  a  few  weeks,  or  may  linger  many 
months.  On  the  other  hand,  when  the  fracture  is  near  the 
base  of  the  neck,  cases  occur  of  recovery,  with  little  lame- 
ness, both  from  the  impacted  and  the  unimpacted  varieties, 
especially  the  former. 

To  facilitate  a  differential  diagnosis,  the  principal  lesions  of 
this  region  will  now  be  described. 

IMPACTED  FRACTURE  OP  THE  BASE  OF  THE  NECK  WITH 
INVERSION. 

This  accident  is  of  rare  occurrence.  Smith  and  Hamilton 
each  cite  but  one  case.  Indeed,  the  structure  of  the  bone,  as 
has  been  shown,  is  such  as  to  insure  an  almost  uniform  ever- 
sion of  the  shaft.  A  specimen  from  a  dissecting-room  has 
enabled  me  to  examine  this  rare  lesion,  and  to  identify  the 
conditions  under  which  it  probably  occurred.  In  this  subject 
(an  old  woman)  the  limb  was  flexed  a  little,  shortened  to  the 
extent  of  three  inches,  and  inverted  so  that  the  patella  faced 
inward ;  the  limb  was  in  slight  abduction,  and  could  neither 
be  everted  nor  brought  to  the  median  line.     The  trochanter 


148 


FEACTUKE  OF  THE  NECK  OF  THE  FEMUR. 


was  felt  to  be  much  thickened.     Upon  examination  of  this 
exceptional  specimen,  the  neck  of  the  bone  was  found  to  be 

firmly  united  at  right  an- 
gles with  the  shaft,  which 
was  split  open  and  spread 
so  widely  as  to  receive  the 
whole  impacted  neck,  leav- 
ing a  fissure  an  inch  or 
more  long  and  a  quarter  of 
an  inch  wide  between  the 
anterior  wall  and  the  neck, 
and  extending  nearly  to  the 
outer  wall  of  the  shaft,  while 
another  similar  fissure  ex- 
isted behind  the  neck.  The 
principal  posterior  fragment 
comprised  the  two  trochan- 
ters with  the  intertrochan- 
teric ridge,  and  also  a  large 
fragment  of  the  external 
portion  of  the  shaft, —  while 
above,  the  region  of  the  great  trochanter  seemed  to  have  been 
comminuted  and  driven  downward  and  inward.  Anteriorly 
the  fracture  had  occurred,  as  usual  in  impacted  fracture, 
along  the  oblique  spiral  line,  although  differing  from  that 
injury,  the  neck  being  deeply  driven  in  behind  this  wall,  from 
which  it  had  slipped  instead  of  turning  upon  it  as  a  hinge. 
The  whole  upper  part  of  the  bone  above  the  trochanter  minor 
seemed  to  have  been  bent  inward,  so  that  the  posterior  inter- 
trochanteric line,  instead  of  inclining  obliquely  to  the  axis  of 
the  shaft,  was  vertical.     The  inversion  was  due  to  the  extent 

1  Figs.  4  and  5,  —  impacted  fracture  with  inversion.  Fig.  4,  posterior 
view ;  Fig.  5,  anterior  view.  The  foreshortening  fails  to  show  the  length 
of  the  tapering  prolongation  of  the  trochanter  minor. 


Fig.  4. 1 


TRACTURE   OF   THE   NECK  OF   THE   FEMUR. 


149 


of  the  comminution,  whicli  had  separated  the  walls  of  the 
shaft  so  as  to  receive  in  the  interval  the  whole  neck  instead 
of  the  posterior  wall  only, 
as  commonly  occurs,  — 
thus  producing  an  ante- 
rior as  well  as  a  posterior 
impaction.  The  shorten- 
ing resulted  both  from 
the  horizontal  position  of 
the  neck  and  from  an  ad- 
ditional upward  displace- 
ment of  the  shaft  caused 
by  the  comminution.  A 
good  deal  of  callus  had 
been  thrown  out  in  va- 
rious directions,  and  the 
movements  of  the  limb 
must  have  been  quite  re- 
stricted. A  curious  spicula  stood  at  right  angles  with  the 
shaft  near  the  lesser  trochanter,  and  may  have  been  a  dis- 
placed fragment  or  the  ossified  insertion  of  the  psoas  tendon. 
The  same  bony  spicula  exists  in  another  specimen  before 
me,  and  is  not  uncommon. 

In  examining  the  accompanying  illustrations,  it  will  be 
seen  that  the  intertrochanteric  ridge  is  split  off,  as  often  hap- 
pens ;  but  in  this  case  it  has  carried  with  it  the  outer  and 
posterior  walls  of  the  shaft,  with  the  two  trochanters. 

Smith!  (^Case  XLVI.)  cites  a  similar  case  of  inversion, 
which  the  accompanying  figure  shows  to  have  resulted  from  a 
similar  cause.  The  posterior  intertrochanteric  ridge,  with  the 
greater  part  of  the  two  trochanters,  has  been  detached  in  a 

1  A  Treatise  on  Fractures  in  the  Vicinity  of  Joints,  etc.  By  Robert 
William  Smith,  M.D.,  M.R.I. A.,  etc.  Philadelphia  and  Dublin,  1850. 
(See  also  Case  XXXVII.) 


Fig.  5. 


150      rRACTURE  OF  THE  NECK  OF  THE  FEMUR. 

mass,  and  so  widely  that  the  neck  of  the  bone  has  slipped 
from  its  anterior  hinge.  In  both  specimens  the  impaction  is 
arrested  near  the  outer  wall  of  the  shaft.  The  entire  neck  in 
my  specimen  can  be  seen  through  the  lateral  fissures,  while  in 
that  of  Smith  its  extremity  is  detected  through  an  interval  of 
the  fragments  near  the  great  trochanter.  A  similar  specimen, 
numbered  248,  in  the  Mutter  Museum  in  Philadelphia,  shows 
neither  inversion  nor  eversion. 


IMPACTED  FRACTURE  OF  THE  NECK  OF  THE  FEMUR  NEAR 
THE  HEAD. 

The  following  cases  of  impacted  fracture  of  the  femur  near 
the  head,  —  one  resulting  fatally,  the  other  in  complete  recov- 
ery, with  the  exception  of  persistent  pain,  —  may  be  regarded 
as  instances  of  fracture  fairly  within  the  capsule.  They  illus- 
trate not  only  the  possibility  of  bony  union  of  the  detached 
articular  extremity,  but  also  the  circumstances  which  con- 
tribute most  frequently  to  its  occurrence,  —  if,  indeed,  they 
are  not  essential  to  it.  In  two  specimens  (Nos.  2111  and 
1540)  in  the  Museum  of  the  Medical  School  of  Harvard 
University,  of  undoubted  bony  union  after  fracture  of  the 
femoral  neck,  the  line  of  separation  is  near  the  head,  which 
is  tilted  obliquely  downward  toward  the  lesser  trochanter, 
as  in  the  following  cases. 

A  man  aged  seventy-six  entered  the  Massachusetts  General 
Hospital,  March  9,  1863,  under  the  charge  of  Dr.  Gay,  who 
has  kindly  furnished  me  with  a  record  of  this  interesting  case. 
The  patient  fell  in  the  evening  upon  the  sidewalk,  striking 
the  right  trochanter.  Feeling  only  that  he  had  received  a 
severe  bruise,  he  crawled  upstairs  alone,  and  sat  in  his  chair 
long  enough  to  read  his  newspaper  before  going  to  bed.  Two 
days  after,  he  entered  the  Hospital.  Upon  examination,  it 
appeared  that  the  right  leg  was  shortened  half  an  inch  ;  the 


FRACTURE   OF  THE  NECK   OF  THE   FEMUR. 


151 


foot  was  everted,  and  could  not  be  inverted  beyond  the  per- 
pendicular ;  the  thigh  could  be  flexed  and  extended  without 
difficulty,  but  with  pain ;  the  trochanter  was  less  prominent 
than  that   of  the  other   side. 


At  the  end  of  two  weeks  he 
died  of  pneumonia,  at  two 
o'clock  in  the  afternoon ;  but 
at  half  past  ten  in  the  morn- 
ing of  that  very  day  he  had 
asked  to  have  the  splints  re- 
moved, saying  that  the  leg 
felt  well,  and  at  the  same 
time  lifting  the  whole  limb 
several  inches  from  the  bed 
without  assistance. 

In  this  interesting  case,  of 
which  an  excellent  illustra- 
tion is  here  given,  the  head 
was  found  to  be  broken  from 
the  articular  extremity  of  the 
neck,  which  was  short  and  thick,  the  fracture  behind  being 
almost  at  the  line  of  junction  of  the  articular  cartilage  and 
the  bone,  while  in  front  it  ran  irregularly  across  the  neck, 

1  Dr.  Gay's  case  of  impacted  fracture  near  the  head.  In  this  speci- 
men the  neck  of  the  bone  was  originally  short  and  stout.  Below  and 
behind  it  the  fracture  follows,  as  nearly  as  may  be,  the  line  of  the 
articular  cartilage,  while  anteriorly  and  above  it  is  about  half  an  inch 
distant  from  this  line.  The  impaction  in  the  recent  state  was  firm,  the 
thin  surface  of  the  neck  at  its  lower  and  posterior  part  having  been 
driven  into  the  cancellous  structure  of  the  head  to  the  depth  of  about 
half  an  inch,  while  the  cancellous  structure  of  the  head  of  the  bone  has 
penetrated  to  the  depth  of  three  quarters  of  an  inch  into  that  of  the  neck, 
this  mutual  impaction  being  very  firm.  The  head  rests  obliquely  upon 
the  lower  fragment,  as  if  the  shaft  had  been  rotated  outward,  opening 
the  anterior  part  of  the  fracture  to  the  width  of  neai'ly  a  quarter  of  an 
inch. 


Fig.  6. 


152  FRACTURE  OF  THE  NECK  OF  THE   FEMUR. 

from  a  quarter  to  half  an  inch  below  this  line.  The  head 
was  bent  on  the  neck  obliquely  backward  and  downward 
toward  the  lesser  trochanter, —  the  tilting  of  the  head  open- 
ing the  fracture  on  the  outside  of  the  neck,  —  and  was  so 
firmly  impacted  that  considerable  force  was  required  to 
withdraw  it.  The  impaction  was  double,  the  shell  of  the 
neck  being  driven  to  the  depth  of  half  an  inch  into  the  head 
behind,  while  the  centre  of  the  head  had  entered  the  cancel- 
lous tissue  of  the  shaft,  being  much  the  more  dense  of  the 
two.  The  patient  was  evidently  not  aware  of  the  existence  of 
fracture,  and  it  would  have  been  impossible  for  the  surgeon  to 
infer  before  death  the  exact  nature  of  the  injury.  It  is  fair 
to  suppose  that  two  bony  fragments  thus  mutually  impacted 
and  held  in  apposition  would  have  united  by  bony  union  had 
the  patient  lived,  and  in  this  case  it  cannot  be  doubted  that 
the  fracture  was  wholly  within  the  capsule.  An  additional 
interest  attaches  to  this  specimen  in  connection  Avith  the  sub- 
joined case  of  fracture,  almost  identical  with  it  in  character, 
and  presenting  unequivocal  bony  union.^ 

The  following  case  of  bony  union,  in  a  fracture  curiously 
resembling  the  preceding,  occurred  in  the  practice  of  Dr.  Gush- 
ing, of  Dorchester,  Mass.,  —  a  practitioner  of  large  experience, 
whose  opinion  in  respect  to  the  general  character  of  an  injury 
of  this  sort  would  be  entitled  to  weight,  even  were  it  not  cor- 
roborated by  the  specimen  here  represented,  the  section  of 
which  shows  unequivocal  evidence  of  fracture.  A  woman 
seventy  years  of  age,  while  reaching  to  wind  up  a  clock,  fell 
upon  her  side.  Dr.  Gushing,  being  called  at  once,  found  that 
although  the  limb  was  not  obviously  displaced,  it  was  so  dis- 

1  For  a  case  of  mutual  impaction  of  the  neck  and  head,  but  compli- 
cated with  a  second  impaction,  old  or  recent,  of  the  base  of  the  neck,  see 
a  paper  by  Thomas  Bryant,  F.  R.  C.  S.,  etc.,  in  the  Medical  Times  and 
Gazette,  May  1,  18G9.  As  the  result  of  this  double  impaction,  there  was 
"some  shortening  of  the  limb,  but  no  eversion  of  the  foot." 


FRACTURE  OF  THE  NECK  OF  THE  FEMUR. 


153 


abled  as  to  leave  no  doubt  of  the  existence  of  a  fracture.  The 
patient  was  laid  upon  her  back,  with  the  knee  flexed  and  two 
pillows  beneath  it.  For  two  and  a  half  or  three  months  she 
kept  her  bed,  and  then  began  to  sit  up  with  the  limb  extended. 
Crutches  were  used  for  six  months  longer ;  then  a  crutch  and 
a  cane ;  but  for  the  last  two  and  a  half  years  neither,  the 
patient  being  able  to  go  about  the 
house  and  a  little  way  out  of  doors. 
There  was  little,  if  any,  shortening, 
and  she  limped  but  slightly.  During 
the  first  few  weeks  she  had  much 
pain  at  the  seat  of  the  injury  and  in 
the  limb,  which  was  gradually  atro- 
phied. Her  health  was  generally  good 
until  near  her  death,  four  years  and 
eleven  months  after  the  accident,  from 
internal  disease. 

In  this  instance,  also,  the  neck  of 
the  femur  is  short  and  thick,  —  the 
line  of  fracture  corresponding  very 
nearly  with  that  of  tlie  articular  carti- 
lage. The  head  of  the  bone  has  been 
depressed  so  that  the  neck  is  now 
nearly  transverse,  —  the  head  being 
also  bent  obliquely  backward  and  downward  toward  the  lesser 
trochanter,  and  the  shaft  rotated  outward.  In  front  the 
neck  of  the  bone  projects  beyond  the  articular  cartilage,  while 
behind  it  is  buried  beneath  it,  as  in  the  preceding  specimen. 
The  neck  is  thus  posteriorly  impacted  into  the  head,  which  in 
bending  backward  opens  a  fissure  in  front,  filled  with  an 
irregular  bony  callus. 

It  was  not  observed  in  this  case  that  the  limb  was  everted, 
as  the  specimen  implies.     At  the  time  of  death  the  foot  was 

1  Dr.  Cushing's  case  of  impacted  fracture  near  the  head,  with  bony  union. 


Fig.  7.1 


154  FRACTURE   OF  THE   NECK   OF   THE   FEMUR. 

straight.     Smith  records  a  case  (No.  LVIII.)  in  which  there 
was  slight  inversion. 

COMMINUTED   FRACTURE   OF   THE   TROCHANTERS   WITHOUT 
IMPACTION. 

Tlie  alleged  injury  thus  described  detaches  the  entire  neck 
from  the  shaft,  and  is  generally  represented  in  museums  by 
specimens,  the  comminuted  fragments  of  which  are  reunited 
in  their  normal  position.  Museum  specimens  of  this  frac- 
ture are  less  frequent  than  those  of  the  common  impacted 
fracture,  and  might  be  still  more  rare  were  it  not  that  the 
impaction,  which  I  conceive  to  be  the  rule  in  fracture  at  the 
base  of  the  neck,  docs  not  always  persist,  being  sometimes 
liberated  by  the  extensive  comminution  of  the  bone,  or  by 
force  subsequently  applied.  The  impacted  bones  are  un- 
doubtedly separated,  in  many  cases  from  want  of  care  both 
in  the  examinatioji  and  in  the  subsequent  treatment  of  the 
patient,  and  likewise  in  the  process  of  their  preparation  as 
specimens. 

It  is  fair  to  suppose  that  local  crepitus  can  be  felt  in  the 
trochanteric  region,  so  extensively  comminuted.  The  lines 
of  fracture  present  great  variety.  The  anterior  and  posterior 
trochanteric  walls,  or  either  of  them,  may  be  detached  entire 
or  in  fragments.  The  posterior  intertrochanteric  ridge  may 
be  split  off  partially  or  wholly,  and  the  trochanter  minor 
broken  off  by  itself.  The  summit  of  the  outer  trochanter, 
and  in  fact  the  whole  upper  region  of  the  shaft,  may  be 
comminuted  and   driven  in  as  by  a  blow  from  above. 

As  in  other  fractures  of  this  part,  inversion  of  the  limb 
is  here  the  rare  exception,  and  eversion  the  rule.  Smith 
cites  twenty-eight  cases  of  extra-capsular  fracture,  of  which 
four  only  were  inverted.  Assuming  that  anterior  impaction 
is  essential  to  inversion,  we  may  seek  the  cause  of  the  latter 


FRACTURE  OF  THE  NECK  OF  THE  FEMUR.      155 

both  in  the  direction  of  the  blow  received  and  in  the  action 
of  the  muscles.  The  influence  of  these  is  well  illustrated  in 
the  case  already  detailed  (Figs.  4,  5),  where  the  mass  of 
large  and  small  rotators  evert  the  upper  fragment  only, 
leaving  the  shaft  to  be  inverted  by  the  anterior  fibres  of  the 
gluteus  medius,  and  especially  of  the  gluteus  minimus,  which 
is  inserted  lower  down.  This  occurs  when  both  the  trochan- 
ters are  detached,  whether  separately  or  (as  in  this  specimen) 
in  a  single  piece.  Smith's  four  cases  of  inve)'sion  ^  sufficiently 
illustrate  these  points,  as  does  also  a  specimen  in  the  Chatham 
Museum,  2  where,  in  addition,  "  an  arch  of  new  osseous  matter 
.  .  .  extends  from  the  anterior  inferior  spinous  process  of  the 
hannch-bone  across  the  joint  to  the  upper  part  of  the  shaft  of 
the  thigh-bone,"  and  which,  it  may  be  inferred  from  its  inser- 
tions, was  the  Y  ligament  and  the  neighboring  fibres  (see  Fig. 
22,  page  74  of  this  volume).  Shortening  not  unfrequently 
results  from  mere  depression  of  the  neck  without  correspond- 
ing rotation  of  the  shaft,  as  in  the  regular  impacted  fracture  ; 
and  the  transverse  neck  may  then  be  displaced  outward  upon 
the  shaft,  so  as  to  resemble  a  hammer  upon  its  handle, 

FRACTUEE    OF   THE   NECK   OF   THE    FEMUR   RESULTING   IN    FALSE 

JOINT. 

The  frequency  of  this  lesion  is  attested  by  the  common 
museum  preparations,  showing  the  hemispherical  head  of 
the  bone  slipping  upon  the  absorbed  and  shortened  neck,  or 
upon  a  broader  surface  with  more  restricted  motion  nearer 
the  shaft.     In  the  latter  case  the  lower  surface  of  the  neck 

^  A  Treatise  on  Fractures  in  the  Vicinity  of  Joints,  etc.  Cases  XXIX., 
XXXVII.,  XXXIX.,  XL VI. 

2  See  the  third  Fascicuhis  of  Anatomical  Drawings,  etc..  Army  Medical 
Museum  of  Chatham;  also,  A  Case  of  Fracture  of  the  Neck  and 
Trochanter  of  the  Thigh-bone  with  Inversion,  etc.  By  George  Gulliver. 
Edinburgh  Medical  and  Surgical  Journal,  vol.  xlvi.  p.  312.     1836. 


156 


FRACTURE  OF  THE  NECK  OF  THE  FEMUR. 


not  unfrequently  rests  upon  a  bony  projection  near  the  lesser 
trochanter.  False  joint  is  a  frequent  result  of  unimpacted 
fracture,  and  is  not  to  be  averted  by  any  special  form  of 
apparatus. 

CRACK   IN   THE   NECK    OF    THE    FEMUR. 

It  is  obvious  that  while  a  simple 
crack  or  fissure  of  the  femur  would 
produce  no  immediate  deformity,  it 
might  yet  give  rise,  as  in  the  radius 
at  the  wrist,  to  lameness  and  inflam- 
mation of  long  duration,  with  corre- 
sponding obscurity  of  diagnosis.  The 
tendency  of  glass  tubes  and  other  brit- 
tle cylinders  to  crack  in  a  spiral  line 
is  well  known ;  and  M.  Gerdy  has  re- 
marked upon  the  occurrence  of  oblique 
or  spiral  fissures  in  the  long  bones, 
producing  at  their  intersection  acute 
angles  like  the  letter  V.  Those  of  the 
tibia  sometimes  exhibit  a  singular 
symmetry  and  mutual  resemblance.^ 
The  annexed  woodcut  (Fig.  8)  repre- 
sents a  portion  of  a  left  femur  from  a 
patient  who  died  under  my  care  at  the 
Massachusetts  General  Hospital,  of 
fracture  and  internal  injuries.  The 
specimen  is  now  in  the  Museum  of 
the  Medical  School  of  Harvard  Uni- 
versity, and    has   been   described   by 


Fig.  8.2 


1  See  Pratique  Journali^re  de  la  Cliirurgie,  p.  67.  Par  Adolphe 
Richard,  Cliiruroien  de  I'llopital  Beaujon,  etc.     Paris,  1868. 

2  Crack  of  tlie  femoral  neck.  Near  the  lesser  trochanter  is  seen  the 
hook-like  extremity  of  the  fissure,  separated  by  a  narrow  interval  of  bone 
from  the  main  line  of  fracture. 


FRACTURE  OF  THE  NECK  OF  THE  FEMUR.      157 

Dr.  J.  B.  S.  Jackson,  Dr.  Mussey,  and  Dr.  Hamilton.  The 
femur  is  large  and  well  marked.  A  spiral  fracture  ascends 
the  shaft  and  winds  round  the  neck,  completely  detaching 
it,  except  at  a  narrow  isthmus  in  front  half  an  inch  wide. 

The  shaft  is  broken  transversely,  eight  inches  below  the 
trochanter.  Here  a  spiral  fissure  begins,  near  the  linea  as- 
pera,  and  winds  upward  and  inward  to  the  front  of  the  bone, 
crossing  the  anterior  intertrochanteric  line  midway  between 
the  trochanters ;  thence  vertically  upward  to  the  outer  edge  of 
the  cartilage ;  thence  transversely  across  the  top  of  the  neck  to 
its  posterior  surface,  here  touching  the  cartilage  again ;  thence 
vertically  down  behind  the  neck  to  a  point  half  an  inch  from 
the  lesser  trochanter,  terminating  on  the  under  side  of  the 
neck  in  an  S-shaped  extremity,  half  an  inch  from  the  point 
where  the  fissure  crosses  the  intertrochanteric  line  in  front. 
The  elastic  bony  pedicle  thus  formed  allows  a  slight  springing 
motion  of  the  head,  but  maintains  it  firmly  in  place. 


158  TRE  TRUE  NECK  OF  THE  FEMUR. 


THE   TRUE    NECK    OF    THE    FEMUR:    ITS    STRUC- 
TURE  AND   PATHOLOGY.i 

I.    STRUCTURE. 

Some  of  the  later  numbers  of  Virchow's  Archives  contain  a 
protracted  yet  interesting  discussion  upon  the  interior  struc- 
ture of  bones,  notably  of  the  head  of  the  femur.  According 
to  Merkel,2  G.  H.  Meyer,  in  1867,  pointed  out  certain  arching 
fibres  in  their  cancellated  structure  as  "a  well-marked  archi- 
tecture, which  stands  in  the  closest  relation  to  the  static  and 
dynamic  forces  of  the  bones." 

In  1870,3  Wolff  made  further  investigation  of  this  subject ; 
and  in  addition,  this  writer  incorporated  into  his  paper  certain 
elaborate  mathematical  calculations  of  Culmann,  of  Zurich, 
showing  that  interior  braces  intended  to  aid  in  supporting  a 
weight  upon  the  end  of  a  cylinder,  curved  like  the  thigh-bone, 
or  like  a  crane  or  derrick,  should  be  placed,  in  order  to  act  to 
Ijest  advantage,  precisely  where  the  trabeculse  of  the  spongy 
tissue  of  this  bone  actually  exist.  "  Nature,"  says  "Wolff, 
"  lias  built  the  spongy  bones  as  an  engineer  would  construct 
a  truss  bridge,  mathematically." 

This  recent  German  investigation,  apart  from  the  mathe- 
matical calculation  which  Merkel  avows  his  inability  to  follow, 
was  anticipated,  so  long  ago  as  1850,  by  the  late  Professor 

1  The  Boston  Medical  and  Surgical  Journal,  Jan.  7,  1875. 

2  Virchow's  Archives,  1874 ;  vol.  lix.  p.  237. 
«  Ibid.,  1870;  vol.  1.  p.  389. 


ITS   STRUCTURE   AND   PATHOLOGY.  159 

Jeffries  Wyman,  who,  in  a  comprehensive  article  upon  this 
subject,^  reached  the  following  conclusions  :  — 

"1.  The  cancelli  of  such  bones  as  assist  in  supporting  the 
weight  of  the  body  are  arranged  either  in  the  direction  of  that 
weight,  or  in  such  a  manner  as  to  support  and  brace  those  cancelli 
which  are  in  that  direction.  In  a  mechanical  point  of  view,  they 
may  be  regarded  in  nearly  all  these  bones  as  a  series  of  *  studs '  and 
'braces.' 

"2.  The  direction  of  the  fibres  in  some  of  the  bones  of  the 
human  skeleton  is  characteristic,  and,  it  is  believed,  has  a  definite 
relation  to  the  erect  position,  which  is  naturally  assumed  by  man 
alone. 

"  These  structures  are  most  clearly  defined  in  adult  and  middle- 
aged  skeletons." 

Dr.  Wyman  illustrates  his  paper  by  diagrams  alone  suffi- 
cient to  demonstrate,  even  to  a  common  mechanic,  an  advan- 
tageous adaptation  of  means  to  end.  An  internal  structure, 
shown  to  be  rectangular  in  the  vertebrae,  radiating  in  the 
tarsal  bones,  and  arched  in  the  neck  of  the  femur,  obviously 
offers  economical  resistance  to  the  weight  it  is  designed  to 
carry.  But  if  doubt  be  still  entertained,  the  laborious  calcu- 
lations of  Culmann,  assumed  to  be  correct,  establish  the  fact 
absolutely,  so  far  as  the  femoral  neck  is  concerned. 

Thus  much  for  the  spongy  structure  of  the  bones  in  general 
(Fig.  1).  We  are  now  to  consider  an  arrangement  peculiar 
to  the  interior  of  the  neck  of  the  thigh-bone.  According  to 
Merkel,  a  section  of  this  may  be  seen  in  an  illustration  designed 
for  another  purpose,  many  years  ago,  by  Pirogoff,  who,  how- 
ever, does  not  allude  to  it.  In  1870,^  Wolff  speaks  of  it  as 
"  a  compact  tissue  beneath  the  trochanter  minor." 

In  1874,  in  an  able  paper  largely  devoted  to  its  description, 

1  Boston  Journal  of  Natural  History,  1850  ;  vol.  vi.  No.  1,  p.  125. 
Report  of  the  Committee  on  Medical  Sciences ;  Transactions  of  the 
American  Medical  Association,  1850. 

2  Virchow's  Archives,  1870 ;  vol.  1.  p.  389. 


160 


THE  TRUE  NECK  OF  THE  FEMUR. 


MerkeP   calls   this   compact   tissue   the 
"  schenkelsporn,"    or    thigh-spur.      The 


"  calcar  femorale,'* 
special  object  of 
Merkel's  paper  is 
to  prove  the  pre- 
dominant impor- 
tance of  this  tissue 
in  sustaining  the 
weight  of  the  body, 
and  to  show  that 
the  strength  of  the 
neck  of  the  femur 
is  mainly  due  to  this 
dense  tissue,  and 
not  to  the  braces  of 
Wolff  and  Culmann. 
Although  a  little 
embarrassed  by 
variations  of  the 
"  spur,"  as  it  ap- 
pears in  different 
preparations,  "be- 
ing in  some  straight,  in  others  curved,"  he  insists  strongly 

1  Virchow's  Archives,  1874 ;  vol.  lix.  p.  237. 

2  A  specimen  showing  repair  of  the  acetabulum  after  hip  disease  is 
here  figured.  The  subject  in  which  it  was  found,  a  boy  of  a  dozen  years, 
was  from  the  dissecting-room.  Large  sinuses  still  remained  open.  The 
head  and  neck  of  the  femur  had  disappeared,  and  the  trochanters  were 
united  to  the  ilium  by  a  narrow  isthmus  of  bone,  an  inch  above  and  be- 
hind the  socket.  The  latter  is  filled  with  a  curious  right-angled  net-work, 
extending  to  some  depth,  the  explanation  of  which  is  not  obvious;  and 
whether  it  be  sought  in  the  influence  of  a  neighboring  rectangular  spongy 
tissue  toward  the  spine  of  the  ischium,  or  in  prolonged  fibres  of  the  ver- 
tical ramus  of  the  ischium  and  the  horizontal  one  of  the  pubes  interlaced 
beyond  their  normal  boundary  in  the  healthy  socket,  or  lastly  in  some 
accidental  traction  upon  tissue  afterward  ossified,  the  interpretation  is 
equally  unsatisfactory.  At  the  bottom  of  the  figure  is  the  tuberosity. 
A  perforation  near  the  socket  was  in  the  track  of  a  sinus. 


Fig.  1.2 


ITS  STRUCTURE  AND  PATHOLOGY.         161 

upon  its  teleological  importance  ;  doubting  whether  the  ar- 
rangement of  the  spongy  tissue  possesses  the  same  signifi- 
cance, because  the  calcaneum  of  man  and  that  of  the  ox,  as 
shown  by  Wolfermann,  really  perform  very  different  func- 
tions, although  they  offer  a  similar  internal  structure,  —  a 
statement  equally  true  of  the  spongy  system  generally.  On 
the  other  hand,  Wolff,  in  a  second  paper,^  replies  that  "the 
calculations  of  Culmann  prove  that  the  '  spur '  is  not  at 
the  point  of  greatest  strain,  nor  yet  where  strength  is  most 
needed ; "  that  "  Merkel's  theory  in  no  way  agrees  with  Cul- 
mann's  calculations,  which  may  be  accepted  as  beyond  con- 
troversy ; "  and  that  "  Merkel  has  ascribed  to  the  '  spur '  a 
wholly  erroneous  importance." 

In  the  following  foot-note,^  Merkel  again  insists  upon  his 
views :  — 

"While  these  sheets  are  being  printed,  I  have  received  the 
work  of  Bigelow  upon  the  Mechanism  of  Dislocation  and  Fracture 
of  the  Hip,  translated  by  Pochhammer  (Berlin,  Hirschwald),  in 
which  the  schenkelsjjom  is  both  described  and  figured  ;  he  does 
not,  however,  follow  out  the  significance  of  the  structure." 

Before  again  expressing  my  own  opinion  of  the  purpose  of 
the  bony  plate  in  question,  it  may  not  be  amiss  to  cite  here 
the  description  alluded  to  by  Merkel,  especially  as  I  do  not 
discover  that  anything  of  importance  has  been  added  to  it 
since  its  publication  in  1869:  — 

ANATOMICAL    STRUCTURE    OF    THE    NECK    OF    THE    FEMUR. ^ 

Let  a  well-developed  femur  be  placed  in  a  vice  with  its  back 
toward  the  observer,  in  its  natural  upright  position,  but  obliquely, 
as  if  the  legs  were  widely  separated,  the  shaft  being  so  far  inclined 

1  Virchow's  Archives,  1874 ;  vol.  Ixi.  p.  417. 

2  Ibid.,  1874 ;  vol.  lix.  p.  251. 

3  Mechanism  of  Dislocation  and  Fracture,  etc.,  p.  120.  Philadelphia, 
Henry  C.  Lea.     1869.     (See  p.  141  of  this  volume.) 

11 


162 


THE  TRUE  NECK  OF  THE  FEMUR. 


that  the  neck  is  horizontal.  Let  a  first  slice  be  now  removed  from 
the  top  of  the  head,  neck,  and  trochanter,  by  a  saw  carried  horizon- 
tally through  the  neck.  Let  a  second 
and  third  slice  be  removed  in  the  same 
waj-,  so  that  the  neck  shall  be  divided 
into  four  horizontal  slices  of  equal 
thickness.-^ 

It  will  be  found  that  the  U2:)per  sec- 
tion exhibits  the  anterior  and  posterior 
walls  of  nearly  equal  thickness,  but 
that,  as  we  approach  the  lower  surface 
of  the  neck,  the  anterior  wall  becomes 
of  great  thickness  and  strength,  while 
the  posterior  wall  remains  thin,  espe- 
cially at  its  insertion  beneath  the  pos- 
terior intertrochanteric  ridge,  where  it 
is  of  the  thinness  of  paper  (Fig.  2). 

TRUE    NECK. 

Upon  examining  the  lower  of  the 
above  sections  in  a  well-marked  bone, 
the  posterior  or  papery  wall  of  the  neck 
will  be  seen  to  be  prolonged  by  radiat- 
ing plates  into  the  cancellous  structure 
beneath  the  intertrochanteric  ridge. 
That  the  thickest  of  these  is  a  continu- 
FiG.  2.2  ation  of  the  true  neck  may  be  shown 

in  another  way.  Let  the  whole  of  the 
posterior  intertrochanteric  ridge,  including  the  back  part  of  both 
trochanters,  be  removed  by  a  narrow,  thin  saw.  The  bone  being 
now  laid  upon  a  table,  let  a  chisel,  or  what  is  better  a  gouge,  be 


1  If  the  head  of  the  bone  be  now  vertically  transfixed  by  a  wire,  the 
sections  may  be  spread  for  examination,  like  a  fan. 

2  Exhibits  a  bird'.s-eye  view  of  a  horizontal  section  of  the  neck  of 
the  femur,  showing  the  posterior  wall  plunging  beneath  the  intertrochan- 
teric ridge,  at  the  angle  where  the  neck  joins  the  shaft.  The  posterior 
wall  is  of  the  thinness  of  paper,  and  here  impaction  occurs.  The  anterior 
wall,  on  the  contrary,  is  seen  to  be  quite  thick,  and  forms  by  its  fracture 
a  hinge  which  is  very  rarely  impacted. 


ITS  STRUCTURE  AND  PATHOLOGY. 


163 


held  perpendicularly  upon  the  cancellous  structure  thus  exposed, 
and  lightly  twirled  until  the  friable  and  spongy  tissue  is  removed, 
and  the  instrument  arrested  by  the  septum,  or  wall,  alluded  to.    To 
expose    its  inner  surface,   the    shaft 
should   be    split   by   a    vertical    and 
curved  section  behind  this  wall,  and 
the  cancellous  structure  removed  in 
the  same  way  (Fig.  4). 

The  septum  will  then  be  distinctly 
seen  as  a  thin,  dense  plate  of  bone 
continuous  with  the  back  of  the  neck, 
and  reinforcing  it,  plunging  beneath 
the  intertrochanteric  ridge  in  an 
endeavor  to  reach  the  opposite  and 
outer  side  of  the  shaft.  At  its  lower 
extremity  it  curves  a  little  forward, 
so  as  to  take  its  origin,  when  on  a 
level  with  the  lesser  trochanter,  from 

the  centre,  instead  of  the  back,  of  the  cylindrical  cavity,  —  a  dis- 
position easily  seen  in  a  transverse  section  of  the  shaft  just  above 
the  trochanter  minor  (Fig.  3).  Or  it  may  be  said  that  the  posterior 
wall  of  the  neck  forks  before  reaching  the  intertrochanteric  line, — 
one  layer  being  seen  upon  the  surface,  while  the  other  dives  be- 
neath the  intertrochanteric  ridge  in  a  vain  attempt  to  reach  the 
outer  wall  of  the  shaft.  If  these  views  be  correct,  the  intertro- 
chanteric ridge  is  simply  a  buttress  erected  for  the  insertion  of 
muscles  upon  and  over  the  true  neck,  by  the  impaction  of  which  it 
is  in  fact  often  split  off  and  detached  in  a  mass,  —  the  force  ex- 
erted by  the  true  neck,  though  slight,  being  nevertheless  an  effort 
to  resist  such  impaction. 


Fig.  3.1 


As  regards  ordinary  spongy  tissue,  the  teleological  question 
is  satisfactorily  answered  in  either  of  two  ways.  We  may 
attribute  its  architecture  to  that  immediate  necessity  which 
in  pathology  builds  a  buttress  to  support  a  bone  curved  by 

1  The  same.  A  section  of  the  shaft  near  the  lesser  trochanter  shows  the 
lower  extremity  of  the  septum,  where  the  wall  is  thicker  and  changes  its 
direction.     (From  a  photograph  taken  in  1861.) 


164 


THE  TRUE  NECK  OF  THE  FEMUR. 


rickets  or  weakened  by  fracture,  or  explain  it  by  a  general 
principle  of  conformation,  in  a  measure  automatic,  developed 
in  the  lapse  of  generations  by  a  frequently  recurring  neces- 
sity, and  still  continuing  to  act  without  immediate  stimulus. 
But  the  purpose  of  the  osseous  plate,  whose  structure  and 

pathology  it  is  the 
main  object  of  this 
paper  to  discuss, 
may  be  at  first  a 
little  less  obvious. 
It  plainly  adds  a 
certain  strength 
to  the  bone ;  and 
yet  in  most  bones 
it  terminates  be- 
neath the  trochan- 
ters in  papery  la- 
mellae wholly  in- 
adequate to  lend 
it  material  support.  It  is  usually  united,  even  to  the  tro- 
chanters, only  by  a  delicate  wall  and  spongy  tissue.  It  obeys 
the  laws  of  similar  bony  structure,  being  feebly  developed  in 
childhood ;  while  later  in  life,  its  absence  in  the  femoral  neck 
impresses  us,  as  do  bone-sections  generally,  with  the  truth  of 
the  observation  of  Henle,  —  that  the  so-called  brittleness  of 
age  depends  not  so  much  on  the  loss  of  animal  substance  as 
upon  the  atrophy  of  the  bony  walls  and  anterior  structure. 

These  varying  appearances  might  well  leave  us  in  doubt  as 
to  the  purpose  of  this  osseous  plate  ;  but  no  doubt  can  exist 

*  "Anatomy  of  impacted  fracture.  The  intertrochanteric  ridge  has 
been  removed,  and  the  cancellous  structure  so  excavated  as  to  exhibit 
the  true  neck  beneath.  The  rod  is  placed  in  a  longitudinal  fissure  by 
which  the  shaft  of  the  bone  has  been  split,  in  order  to  exhibit  the  true 
neck  from  within.     (From  a  photograph  taken  in  1861.) 


Fig.  4.1 


ITS  STRUCTURE  AND  PATHOLOGY. 


165 


in  the  mind  of  one  who  examines  an  exceptionally  well- 
marked  adult  bone.  Such  a  bone 
fell  under  my  observation  in  1861 
(Fig.  4).  The  dense  plate  is  there 
a  continuation  of  the  neck,  com- 
pleting the  interval  everywhere 
except  at  its  upper  part.  In 
this  form  it  adds  greatly  to  the 
strength  of  this  part  of  the  femur, 
while  the  trochanters  and  their 
ridge  erected  upon  it  both  rein- 
force it  and  give  attachment  to 
the  muscles. 

This  may  be  again  shown.  In 
a  back  view  of  the  femur  (Fig,  5) 
the  neck  appears  as  a  pyramid, 
with  its  base  to  the  trochanters. 


Fig.  5.1 


Fig.  6.2 


1  Rear  view  of  left  femur  with  and  without  the  trochanters.  The 
removal  of  these,  in  the  left-hand  figure,  exposes  the  true  neck. 

2  Side  view  of  the  same.  While  these  views  are  designed  to  exhibit 
the  true  neck,  it  is  not  denied  that  the  trochanteric  shell  helps  to  stiffen 
the  curving  shaft  and  to  sustain  any  weight  resting  upon  the  head  of  the 
bone;  especially  through  the  intervention  of  the  upper  and  horizontal 
part  of  the  neck. 


166 


THE  TKUE  NECK  OF  THE  EEMUR. 


The  cylindrical  shaft  also  spreads  as  it  rises  to  meet  the  tro- 
chanters. In  a  side  view  (Fig.  6)  it  is  seen  that  both  these 
cylinders,  joined  at  their  bases,  are  flattened  from  front  to 
back,  and  are  continuous  in  shape  and  direction,  although 
surmounted  at  their  junction  by  the  trochanteric  promi- 
nences. If  we  now  remove  the  trochanters  with  their  con- 
necting ridge  (Figs.  5  and  6),  it  may  be  again  observed  that 
what  we  have  called  the  true  neck  maintains  the  continuity 
of  the  shaft.  It  no  longer  resembles  a  "  spur,"  with  its  edge 
exposed  by  excavating  the  wall,  as  in  Merkel's  preparations. 
Thus  denuded,  the  shaft  has  an  air  of  symmetrical  strength. 
It  is  flattened  to  resist  weight,  like  a  bone  curved  by  disease, 
while  the  trochanters  seem  to  have  been  added  for  a  different 
purpose  (Fig.  7).^ 

Unfortunately,  bones  like  that  above  alluded  to  are  rare. 
The  true  neck  is  often  at  best  but  an  ineffectual  attempt  to 
bridge  the  interval  beneath  the  trochanters,  as  seen  in  Mer- 
kel's figures ;  while  in  the  latter  half  of  life  it  degenerates 

1  Diagram  of  a  section  of  the  head  of  the  femur  of  a  sheep,  showing 
a  deep  trochanteric  fossa.  If  this  fossa  were  filled  with  spongy  tissue  (as 
seen  beneath  the  dotted  line),  the  posterior  neck 
would  be  partially  concealed,  as  in  the  human 
femur.  The  analogy,  whether  true  or  not,  is  too 
striking  to  be  overlooked.  A  deeper  fossa  ex- 
ists in  certain  animals,  especially  South  African 
ruminants,  of  which  I  examined  sections  in  the 
Hunterian  Museum  in  1868.  In  this  specimen 
the  tendon  inserted  at  the  bottom  of  the  fossa 
is  prolonged  into  the  spongy  tissue  by  radiating 
lamellae,  which  intersect  concentric  arches  as 
represented  in  the  diagram,  and  resist  traction 
to  great  advantage. 

In  examining  a  number  of  preparations  lately 

made  by  my  friend  Dr.  Dwight,  I  am  satisfied 

that  the  tendency  of  what   I   have  called   the 

true  neck  is  to  attach  itself  below,  where  it  becomes  thin,  as  a  tangent  to 

the  inside  of  the  cylinder  of  the  shaft ;  and  also  that  it  may  be  tolerably 

well  pronounced  in  a  subject  six  or  eight  years  of  age. 


ITS  STRUCTURE  A^^D  PATHOLOGY. 


167 


into  papery  plates,  radiating  downward  from  a  point  near  the 
lesser  trochanter. 

Weakened  in  this  way  both  by  its  own  tenuity  and  by  its 
slender  union  to  the  trochanteric  ridge,  the  true  neck  has 
great  practical  interest  for  the  surgeon.  Even  the  adult 
femur  is  generally  defective  in  construction  at  this  point ;  and 
here  occurs  the  most  common  form  of  fracture,  —  namely,  the 
posterior  impacted  fracture  of  the  base  of  the  neck. 

II.  —  PATHOLOGY. 
IMPACTED  PRACTUEES. 


POSTERIOR  IMPACTED  FRACTURE  OF  THE  BASE  OF  THE  CERVIX. 

The  posterior  impacted  fracture  of  the  base  of  the  cervix 
often  occurs  in  old 
people.  I  have  met 
with  it  also  in  middle 
life,  and  do  not  hesi- 
tate to  express  the  be- 
lief that  it  is  the  most 
common  of  the  frac- 
tures of  the  neck  of 
the  thigh-bone.     That 

^  Front  view  of  right 
femm-,  showing  the  frac- 
tured cervLx  bending  like 
a  hinge  at  the  anterior 
intertrochanteric  line,  to 
allow  the  posterior  im- 
paction. The  head  of 
the  bone  leans  more  dis- 
tinctly from  the  observer 
than  the  perspective  in- 
dicates. 


168 


THE  TRUE  NECK  OF  THE  FEMUR. 


it  has  not  been  so  considered  may  be  explained  by  the  fol- 
lowing considerations  :  — 

1.  It  has  been  generally  recognized  only  of  late  years. 

2.  The  injury  may  be  a  comparatively  slight  one. 

3.  Its  signs  are  in 
some  cases  a  short- 
ening and  eyersion 
hardly  perceptible. 

4.  When  it  unites, 
there  may  be  no  lame- 
ness to  attract  subse- 
quent attention. 

5.  When  it  proves 
fatal  before  union,  the 
impaction  may  have 
been  disengaged  by 
manipulation  or  other- 
wise, during  life  or 
after  death, -'—espe- 
cially by  macerating 
the  specimen  for  pres- 
ervation. 

6.  On  the  other  hand, 
unimpacted  fracture  of 
the  small  part  of  the 

neck,  usually  supposed  to  be  most  common,  is  marked  by 
prominent  symptoms.  It  entails  great  and  persistent  lame- 
ness, inviting  attention  and  examination  after  death,  however 
remote,  and  the  specimen  when  obtained  is  unmistakable. 

The  displacement  varies  greatly  in  degree.  One  wall  only 
—  the  posterior  one  —  is  impacted   at   the   intertrochanteric 

^  Rear  view  of  same,  showing  the  cervix  impacted  beneath  the  pos- 
terior intertrochanteric  line.  The  head  of  the  bone  leans  toward  the 
observer. 


Fig.  91 


ITS  STRUCTURE  AND  PATHOLOGY. 


169 


line,  where  the  bone  is  a  mere  shell,  driving  the  true  neck,  or 
the  remains  of  it,  farther  beneath  the  trochanters,  and  some- 
times detaching  the  latter.  The  firm  anterior  wall  resists 
impaction,  but  bends  at  the   line  of  fracture  as  a  hinge.     If 

this  hinge  were  ver- 

tical,  the  shaft  would  y"" 

be  only  everted; 
while  if  it  were 
transverse,  the  neck 
would  be  only  bent 
and  the  leg  short- 
ened. But  as  the 
hinge  stands  at  an 
angle  of  about  45°, 
shortening  and  ever- 
sion  are  nearly  equal 
(Figs.  8,9,10).  Im- 
paction, when  slight, 
is  detected  by  a  dif- 
ficulty of  inverting 
the  foot  rather  than 
by  actual  eversion ; 
and  the  shortening 
may  seem  doubtful. 
It  is  needless  to 
say  that  the  rotated 

trochanter  still  sweeps  through  an  arc  of  which  the  head  of 
the  femur  is  the  centre,  and   that   there   is   no  crepitation. 

1  Horizontal  section  of  the  same,  showing  the  anterior  hinge  and  the 
posterior  impaction.  The  dotted  line  shows  the  normal  position  of  the 
head.  The  patient  who  furnished  the  specimen  from  which  these  figures 
were  taken  was  seventy-two  years  of  age.  It  will  be  seen  that  the  prolon- 
gation of  the  true  neck  has  disappeared  by  senile  atrophy,  leaving  only  a 
few  radiating  lamellae.  The  specimen  is  of  exceptional  interest  as  show- 
ing this  form  of  impaction  with  little  comminution  or  other  injury  of 
the  bone. 


Fig.  10.1 


170 


THE  TRUE  NECK  OF  THE  FEMUR. 


Shortening  and  eversion,  however  inconsiderable,  point  di- 
rectly to  this  lesion.  A  large  number  both  of  cases  and  of 
specimens  are  referrible  to  this  type,  —  impaction  behind, 
with  a  hinge  in  front,  each  at  its  respective  intertrochanteric 
line.  In  some  of  these  specimens  the  neck  is  bent  down 
nearly  to  a  right  angle  with  the  shaft. 

The  remaining  varieties  of  fracture  of  the  femoral  neck  are 
susceptible  of  classification,  and  deserve,  for  the  purpose  of 
comparison,  to  be  mentioned  in  this  connection. 


IMPACTED  FRACTUKE  OF  THE  HEAD  OF  THE  FEMUR. 

The  impacted  fracture  of  the  head  of  the  femur  is  rare,  and 
I  do  not  believe  it  possible  to  distinguish  it  from  that  just 

described,  even  if  it  were  de- 
sirable to  do  so.  In  three 
cases  I  have  known  there 
was  the  same  shortening  and 
eversion,  and  the  same  com- 
parative ability  to  move  the 
limb.  A  woman  who  died 
of  the  injury  was  able  at  all 
times  to  get  into  and  out  of 
bed  with  but  little  assistance, 
and  the  trochanter,  when  ro- 
tated, swept  through  its  arc. 
There  was  no  union.  The 
small  extremity  of  the  cervix 
was  rather  "  rebated  "  than 
impacted  with  the  head  of 
the  femur,  and  the  fracture 
was  "within  the  capsular  ligament "^  (Fig.  11). 

1  Impacted  fracture  of  the  head  of  the  fennxr.     The  patient  who  fur- 
nished this  specimen  died  of  pneumonia  in  two  weeks. 

2  See  extracts  from  the  Proceedings  of  the  Society  for  Medical  Improve- 
ment; Boston  Medical  and  Surgical  Journal,  No.  1  (1875),  p.  20. 


11.1 


ITS  STRUCTURE  AND  PATHOLOGY. 


171 


The  firmness  of  the  fragments  in  such  a  case  is  chiefly  due 
to  the  dense  central  cone  of  spongy  tissue  which  projects  from 
the  head  of  the  bone  and  impacts  itself  in  the  friable  cavity  of 
the  cervix.  If  the  cylinder  of  the  cervical  portion  is  simulta- 
neously impacted  into  the  head  of  the  femur,  around  the  base 
of  the  cone,  immobility  is  doubly  insured. 

I  have  elsewhere  expressed  the  opinion  that  these  condi- 
tions are  essential  to  the  very  exceptional  occurrence  of  bony 
union  of  the  small  part  of  the  cervix.  In  default  of  anchylo- 
sis the  neck  is  doubtless  absorbed,  presenting  after  a  time 
the  familiar  conditions  of  an  old  "  ununited  fracture."  So 
that  permanent  lameness  may  result  from  a  fracture  which, 
by  simulating  impaction  of  the  base,  promises,  at  first,  bony 
union,  with  comparatively  little  deformity. 


111  ^  .„Jif^  . 


Fig.  12.1 


Fig.  13. 


1  Figs.  12  and  13,  —  impacted  fracture  of  the  base  with  inversion.  The 
anterior  view  (Fig.  12)  shows  the  neck  slipped  off  its  thick  hinge,  into 
the  cavity  of  the  shaft.  To  allow  this,  the  whole  trochanteric  mass  must 
have  been  detached,  as  seen  in  the  rear  view  (Fig.  13). 


172  THE   TRUE   NECK   OF   THE   FEMUR. 

IMPACTED  FRACTURE   OF  THE  WHOLE   BASE   OF   THE    CERVIX, 
WITH    INVERSION. 

The  very  rare  impacted  fracture  of  the  neck  with  inversion, 
instead  of  eversion  which  is  the  rule,  occurs  when  the  neck  in 
front  slips  off  its  hinge  into  the  cavity  of  the  shaft.  This  is 
hardly  possible,  as  I  have  elsewhere  shown,  unless  the  whole 
posterior  intertrochanteric  mass,  including  the  trochanters,  is 
fairly  detached  (Figs.  12,  13). 


UNIMPACTED    FRACTUEES. 

FRACTURE  OF  THE  SMALL  PART  OF  THE  CERVIX  OF  THE  FEMUR. 

The  fracture  of  the  small  part  of  the  cervix  of  the  femur, 
which  has  been  usually  described  as  the  most  common  frac- 
ture of  elderly  persons,  and  erroneously  as  deriving  impor- 
tance from  being  within  the  capsular  ligament,  is  a  loose 
fracture,  with  no  interlocking  to  maintain  the  immobility 
of  the  small  extremities,  even  were  they  disposed  to  bony 
union.  Familiarly  characterized  by  increased  motion,  great 
pain  and  disability,  much  shortening,  marked  eversion,  and 
the  rotation  of  the  shaft  upon  its  axis  instead  of  through 
an  arc,  it  is  not  likely  to  be  mistaken  even  at  first  sight. 
But  its  relations  to  the  capsular  ligament  are  probably  un- 
certain, owing  to  differences  in  the  size  and  insertions  of 
the  latter. 

COMMINUTED    FRACTURE   OF   THE  TROCHANTERS   AND   SHAFT. 

Lastly,  when  the  trochanteric  portion  of  the  femur  is  com- 
minuted, the  detached  neck  and  head  of  the  bone  may  be  very 
variously  placed  in  bony  union,  both  as  to  angle  and  as  to  the 
part  which  becomes  subsequently  attached  to  the  shaft. 


ITS  STRUCTURE  AND  PATHOLOGY.         173 

In  completing  the  list  of  injuries  to  be  borne  in  mind  while 
examining  a  hip  with  reference  to  impacted  fracture,  we  may 
enumerate  dislocation,  sprain,  crack,  the  rare  separation  of 
the  epiphyses,  and  the  fracture  of  the  acetabulum  into  the 
pelvis. 

TREATMENT. 

A  few  words  of  a  practical  character  may  be  added  here. 
Apart  from  dislocation,  the  main  object  of  examination  is 
to  decide,  with  reference  to  treatment,  whether  a  fracture 
is  loose  or  impacted.  I  have  demonstrated  here  and  else- 
where the  following  points,  illustrating  the  difficulty  of  fur- 
ther diagnosis :  — 

1.  The  common  impacted  fracture  of  the  base  of  the  neck 
and  the  rare  one  of  the  head  may  be  indistinguishable  from 
each  other. 

2.  A  fracture  seemingly  impacted  and  promising  bony 
union  may  yet  result  in  ligamentous  union  with  correspond- 
ing lameness. 

3.  In  loose  fractures  with  great  shortening,  it  may  be  some- 
times difficult  to  distinguish  a  fracture  of  the  small  part  of 
the  neck,  which  does  not  promise  bony  union,  from  that  of 
the  trochanters,  which  does. 

But  while  an  accurate  diagnosis  of  such  cases  is  some- 
times absolutely  impossible,  no  embarrassment  need  be 
felt  in  the  treatment  of  these  injuries.  Their  treatment  is 
simple. 

If  to  extend  a  limb  means  to  draw  it  down,  impacted  frac- 
ture and  whatever  resembles  it  should  never  be  extended,  but 
only  steadied  by  weight  or  splint.  On  the  other  hand,  a  loose 
fracture  with  decided  shortening  should  be  first  drawn  down 
to  something  like  its  normal  length.  Or,  more  briefly,  treat- 
ment consists  in  immobility,  with  the  previous  extension  of  a 
loose  fracture. 


174         THE  TRUE  NECK  OF  THE  FEMUR. 

A  careful  review  of  these  injuries  thus  leads  back  to  a  prac- 
tical rule  already  usually  adopted.  But  it  leads  further,  and 
demonstrates  conclusively  that  prolonged  and  active  flexion 
and  rotation  of  the  hip,  in  search  of  positive  signs,  is  more 
than  superfluous.  Without  anesthesia  it  entails  needless 
suffering ;  and  with  or  without  it,  by  loosening  impaction  or 
lacerating  tissues,  it  may  be  disastrous. 

Tlie  question  of  dislocation  settled,  a  very  brief  and  gentle 
examination  is  alone  admissible,  —  chiefly  to  determine  (1)  the 
degree  of  shortening ;  (2)  whether  the  shaft  rotates  through 
an  arc  or  on  its  axis.  The  most  useless  and  damaging  exam- 
ination is  that  by  quick  and  persistent  rotation,  and  by  flexion 
of  the  thigh  as  far  as  a  right  angle. 

The  prognosis,  if  the  patient  lives,  is  favorable  for  bony 
union,  except  in  the  case  of  loose  fracture  of  the  small  part 
of  the  cervix,  which,  if  not  readily  distinguished,  should  be 
disturbed  as  little  as  possible. 

Familiarity  with  the  posterior  impacted  fracture  of  the  base 
of  the  neck  will  remove  the  most  frequent  source  of  doubt  in 
the  diagnosis  of  injuries  of  this  region ;  and  the  sooner  the 
old  classification  of  "  intra  and  extra  capsular  fractures "  is 
abandoned,  the  better  it  will  be  for  science,  for  diagnosis,  and 
for  treatment.  In  the  interest  of  the  patient  and  of  treat- 
ment the  question  should  be,  "  Is  the  fracture  loose  or 
impacted  ? "  and  science  is  often  compelled  to  rest  satisfied 
when  this  is  settled. 


FRACTURE  OF  THE  NECK  OF  THE  THIGH-BONE.        175 


FRACTURE   OF   THE  NECK   OF   THE 
THlGH-BONE.i 

Few  accidents  are  more  common  or  more  important  than 
this  ;  and  few  give  rise  to  greater  doubt  in  diagnosis.  I  aim 
in  this  lecture  at  such  a  general  view  of  the  subject  as  will 
be  useful  to  you  in  practice. 

The  fractures  of  the  head  of  the  femur,  or,  as  they  are 
usually  called,  of  "  the  hip,"  are  tolerably  well  recited  in  the 
books.  The  principal  ones  are  three  in  number.  First,  the 
so-called  fracture  within  the  capsular  ligament,  which  I  call 
fracture  of  the  middle  of  the  neck ;  and,  second,  two  others, — 
the  impacted  fracture  of  the  base  of  the  neck,  and  the  im- 
pacted fracture  of  the  upper  end  of  the  neck;  the  one  being 
an  impaction  of  the  neck  into  the  trochanters,  the  other  an 
impaction  of  the  neck  into  the  head  of  the  bone. 

This  leaves  for  further  consideration  only  the  irregular 
fractures,  or  set  of  fractures,  about  the  trochanters,  which 
though  not  susceptible  of  classification  fortunately  do  not 
need  to  be  classified  in  treatment ;  they  may  be  considered 
as  one. 

Contrary  to  the  usual  belief,  I  regard  the  impacted  fracture 
of  the  base  of  the  neck  into  the  trochanters  as  the  most  fre- 
quent fracture  of  the  head  of  the  femur.  Let  us  first,  how- 
ever, consider  the  one  usually  known  as  "the  fracture  of  old 
people," — that  "within  the  capsular  ligament"  as  it  has  been 
usually  called, —  or,  as  I  term  it,  "the  fracture  of  the  middle 
of  the  neck." 

We  have  in  the  hospital  wards  four  cases  of  injury  to  the 
hip ;  three  are  the  usual  impacted  fracture,  and  one  the  frac- 

1  A  Clinical  Lecture.    January,  1880.     Now  first  published. 


176   FRACTURE  OF  THE  NECK  OF  THE  THIGH-BONE. 

ture  I  am  now  about  to  speak  of.  It  usually  occurs  in  late 
life,  when  the  outline  of  the  neck  of  the  femur  is  no  longer 
w^hat  it  was  in  the  young  adult.  In  the  perfect  femur  the 
neck  is  a  flat  pyramid,  with  its  apex  above,  and  its  base 
spreading  from  one  trochanter  to  the  other.  Its  smallest 
part  is  next  the  head.  Later  in  life  the  neck  changes  in 
shape,  and  is  smallest  at  the  middle,  where  it  breaks.  Its 
texture  does  not  become  more  brittle,  as  usually  stated,  but 
there  is  less  bone.  Its  interior  is  so  changed  that  the  neck 
is  but  a  thin  and  almost  papery  shell,  which  may  yield  to 
slight  injury.  Sometimes  the  patient  is  even  supposed  to 
have  broken  his,  or  rather  her,  hip  (for  the  injury  occurs  more 
frequently  in  women)  before  falling.  The  neck  yielding  near 
its  middle,  the  limb  is  left  at  the  mercy  of  the  muscles,  hangs 
loose,  and,  in  an  erect  posture,  swings.  The  muscles  of  the 
haunch  evert  the  trochanter,  and  of  course  the  toe.  There 
may  be  a  considerable  shortening,  —  two  inches  and  more. 

I  have  often  mentioned  a  patient  I  once  saw  in  the  street, — 
a  lady  who  fell,  and  when  raised  and  supported  by  the  bystand- 
ers had  a  swinging  leg,  everted  toe,  and  the  limb  so  shortened 
that  I  diagnosticated  a  fracture  of  the  neck  of  the  thigh-bone 
across  the  street.  Such  a  patient  placed  upon  a  bed  is  usually 
in  great  pain,  because  the  muscles  are  nipped  by  the  displaced 
fragments,  the  pinching  of  the  soft  parts  being  the  usual  cause 
of  pain  in  a  fracture.  So  great  is  the  eversion  that  the  foot 
generally  lies  upon  its  outside.  Under  these  circumstances  it 
is  useless  to  try  to  get  crepitus;  the  effort  is  not  only  produc- 
tive of  pain,  but  also  damages  the  part.  The  evidence  is  suffi- 
cient without  it.  Crepitus  can  be  got,  however,  by  drawing  the 
limb  down  until  the  fragments  rub  together  in  apposition. 

The  prognosis  of  this  fracture  is  unfavorable  as  to  union, 
perhaps  in  proportion  to  the  displacement ;  also  to  the  age  of 
the  patient  and  her  health.  The  accident  is  sometimes  grave, 
and  may  be  a  fatal  one.     The  patient  may  die  in  a  period  vary- 


FRACTURE   OF  THE   NECK  OF   THE   THIGH-BONE.        177 

ing  from  a  few  days  to  a  year  after  the  accident,  gradually  worn 
out.  On  the  other  hand,  the  bone  generally  unites  by  ligament, 
and  the  patient  is  able  to  walk  with  crutches,  or  a  crutch  and 
a  cane.  If  such  a  patient  is  finally  able  to  walk  with  a  cane, 
the  accident  was  probably  not  the  one  we  are  considering,  but 
rather  one  of  the  impacted  fractures,  or  a  fracture  of  the  tro- 
chanter. The  ligament  which  unites  the  bone  may  be  longer 
or  shorter,  and  the  mobility  greater  or  less.  The  neck  will 
eventually  become  absorbed,  and  the  head  of  the  bone  may 
after  a  while  rest  directly  upon  the  shaft  of  the  femur.  The 
explanation  of  non-union  is  to  be  found  in  the  mobility  of  the 
fragments  and  the  impossibility  of  keeping  them  in  apposi- 
tion ;  and  there  is  also  something  in  the  fact  that  the  upper 
fragment  does  not  contribute  its  share  to  the  mutual  union, 
being  suspended  from  the  pelvis  by  the  capsular  ligament 
only,  for  the  ligamentum  teres  is  not  a  true  ligament,  but 
merely  a  fasciculus  for  the  passage  of  vessels. 

I  have  already  said  that  the  fracture  of  the  middle  of  the 
neck  is  not  the  most  common  one.  It  is,  however,  the  most 
striking  and  the  most  persistent  in  consecutive  results.  This 
subsequent  persistence  of  deformity  or  lameness  directs  atten- 
tion to  the  hip  bone  at  an  autopsy,  and  the  specimen  is  saved; 
while  other  fractures  resulting  in  bony  union  are  forgotten,  or 
if  the  head  of  the  bone  is  procured  it  is  so  repaired  as  to 
leave  the  exact  character  of  the  injury  in  doubt.  Consequently 
fractures  of  the  middle  of  the  neck  are,  or  have  been,  the  most 
familiar  by  reason  of  their  frequency  as  museum  specimens. 
It  is  also  the  fracture  most  easily  diagnosticated.  In  fact  it 
can  hardly  be  mistaken  even  when  seen  for  the  first  time. 

The  most  common  fracture  is  the  impaction  of  the  base  of 
the  neck  into  the  trochanters.  It  deserves  to  be  thoroughly 
considered,  because  its  signs  are  sometimes  not  at  all  satisfac- 
tory to  the  surgeon  who  is  unfamiliar  with  them.  They  de- 
pend upon  an  anatomy  comparatively  new,  and  which  was  first 

12 


178       FRACTURE  OF  THE  NECK  OF  THE  THIGH-BONE. 

described  by  myself.  We  have  seen  that  the  neck  of  the 
femur  is  seated  upon  the  oblique  line  of  the  trochanters. 
When  the  fracture  is  impacted  the  neck  is  driven  into  the 
trochanters.  But  there  is  a  rule  about  this ;  and  that  is,  the 
neck  is  always  impacted  more  behind  than  in  front ;  and  the 
head  of  the  bone  is  in  this  way  bent  backward,  or  —  which  is 
the  same  thing  —  the  shaft  of  the  femur  is  rotated  outward. 
From  this  results  the  eversion  which  belongs  to  the  accident. 
The  cause  of  the  unequal  impaction  is  a  difference  in  the 
thickness  of  the  walls  of  the  neck  in  front  and  behind.  In 
front  the  bone  is  thick ;  behind  it  is  exceedingly  thin ;  and  it 
is  behind  that  it  yields.  The  bone  has  a  thickness  of  per- 
haps an  eighth  of  an  inch  along  the  front  of  the  neck,  and  in 
some  cases  more ;  behind  it  has  only  the  thickness  of  paper. 

The  head  and  neck  of  the  femur  have  been  repeatedly  sawed 
longitudinally  and  vertically ;  and  anatomists  (notably  the 
late  Jeffries  Wyman)  have  given  details  of  the  very  beauti- 
ful cancellous  structure,  whose  fibres  are  arranged  in  radii, 
arches  and  stringers,  to  support  and  suspend  the  head  of  the 
bone  from  the  trochanter.  But  a  transverse  section  of  the 
head  remained  to  be  made.  For  this  purpose  the  femur 
should  be  placed  with  its  back  toward  you,  upright,  but  as  if 
the  patient  were  straddling,  so  as  to  bring  the  neck  of  the 
femur  to  a  horizontal  position.  Now,  if  you  slice  off  the 
top  of  the  femur,  neck,  and  trochanters,  and  then  take  a 
second,  a  third,  and  perhaps  a  fourth  horizontal  slice,  you 
will  find  as  you  get  toward  the  bottom  of  the  neck  that  the 
anterior  wall  is  so  thick,  and  the  posterior  wall  so  thin,  as  to 
leave  no  doubt  of  the  facts  I  have  mentioned.  The  posterior 
wall  which  yields  actually  starts  thick  from  the  head ;  but 
instead  of  being  inserted  thick  into  the  trochanters,  it  plunges 
beneath  them  in  the  direction  of  the  shaft  of  the  femur.  If 
it  were  inserted  there,  it  would  be  strong ;  but  in  an  attempt 
to  gain  the  shaft  of  the   femur  it  becomes  more  and  more 


FRACTURE   OF  THE   NECK   OF  THE   THIGH-BONE.        179 

attenuated  until  it  loses  itself  and  disappears  in  a  series  of 
radiating  papery  plates.  This  construction  was  first  pointed 
out  in  my  paper  on  "  The  Mechanism  of  Dislocation  and 
Fracture  of  the  Hip,"  and  was  some  years  afterward  again 
described  by  Merkel,  as  the  "  Schenkelsporn,"  in  a  paper  in 
Virchow's  Archives ;  and  since  by  Dr.  Dwight,  of  Boston. 

The  anatomy  of  this  part  of  the  femur  illustrates  and  ex- 
plains the  important  signs  which  enable  us  to  identify  the 
impacted  fracture  of  the  base  of  the  neck.  The  anterior  wall 
of  the  neck  being  thick  is  not  impacted ;  the  posterior  wall 
being  thin  is  crushed  and  driven  together.  The  thick  ante- 
rior wall  rocks  upon  its  broken  edges  as  a  hinge,  but  is  rarely 
otherwise  displaced.  You  see  this  in  these  museum  speci- 
mens, of  which  ours  has  a  dozen  or  twenty.  Specimens  in 
other  museums  also  show  that  this  impacted  fracture  obeys 
a  constant  law.  The  neck  bends  only  at  its  anterior  hinge, 
while  it  is  impacted  posteriorly.  This  explains  eversion. 
The  whole  limb  is  everted. 

A  word  as  to  shortening.  If  we  hold  a  common  hinge 
horizontally,  a  femur  attached  to  the  lower  part  of  the  hinge 
would  be  shortened  by  just  so  much  as  we  shut  the  latter.  If 
on  the  other  hand  the  hinge-joint  were  vertical,  there  would 
be  no  shortening,  but  the  shaft  of  the  femur  would  be  everted 
when  the  hinge  was  bent.  Now,  as  the  inter-trochanteric  line 
is  neither  vertical  nor  horizontal,  but  oblique  at  an  angle  of 
forty-five  degrees,  the  hinge  which  it  represents  is  half  verti- 
cal and  half  horizontal.  Its  movement  is  one  of  half  eversion 
and  half  shortening,  —  of  shortening  in  proportion  to  the 
eversion,  and  eversion  in  proportion  to  the  shortening.  A 
limb  much  everted  is  a  good  deal  shortened,  and  when  it  is 
little  everted  it  is  but  little  shortened. 

Suppose  the  impaction  is  great.  There  is  no  difficulty  in 
determining  its  existence ;  the  eversion  and  the  shortening 
both  announce  it.     But  suppose  that  the  impaction  is  slight. 


180       FRACTUEE  OF  THE  NECK  OF  THE  THIGH-BONE. 

In  this  case  you  have  hardly  any  eversion  and  hardly  any 
shortening;  so  that  in  fact  you  may  be  in  doubt  whether  the 
limb  is  shortened  or  not.  Now,  here  is  a  rule  for  determining 
the  existence  of  an  impacted  fracture  where  the  impaction  is 
slight.  Let  the  patient  be  directed  to  evert  the  feet,  —  first 
the  sound  one,  and  then  the  other.  One  is  everted  as  easily 
as  the  other.  But  let  him  be  directed  to  invert  them,  and  you 
will  find  that  while  he  can  invert  the  sound  one,  the  affected 
limb,  by  reason  of  its  impaction  behind,  cannot  be  inverted 
quite  as  much.  So  that  in  the  very  common  accident  of  a 
slight  impaction  of  the  base  of  the  neck  of  the  femur  you 
may  accept  as  its  pathognomonic  sign  an  undemonstrable 
or  hardly  perceptible  shortening,  with  only  a  diminution  of 
the  power  of  inversion.  In  other  words,  inability  to  invert 
is  eversion. 

This  throws  light  upon  many  cases  of  injury  to  the  hip, 
about  which  even  good  surgeons  not  unfrequently  differ. 
Cases  we  have  now  in  the  hospital  illustrate  these  fractures. 
A  patient  upstairs,  a  female,  whom  you  saw  on  Saturday, 
sixty-five  years  of  age,  fell  upon  her  hip  on  a  slanting,  icy 
sidewalk.  She  came  in  here  five  hours  afterward.  She  had 
pain  at  the  trochanter,  increased  by  motion,  and  tenderness 
on  pressure.  She  was  disabled  so  far  as  the  use  of  the  limb 
goes.  The  eversion  was  in  this  case  obvious,  the  foot  stand- 
ing at  an  angle  of  about  forty-five  degrees,  and  the  shorten- 
ing being  three-quarters  of  an  inch.  There  was  no  crepitus. 
These  signs  indicated  impaction. 

In  another  case  the  injury  is  less  marked.  It  illustrates 
better  what  I  have  said  of  slight  impaction.  The  patient,  also 
a  woman,  is  twenty-nine  years  old.  She  fell  upon  the  side- 
walk, upon  her  hip,  two  days  before  coming  here.  There  was 
pain  over  the  great  trochanter  and  its  neighborhood,  much 
increased  by  motion,  and  of  course  tenderness  on  pressure, 
and  disability.      There  was  an  inability  to  invert  the  foot 


FRACTURE  OF  THE  NECK  OF  THE  THIGH-BONE.    181 

beyond  the  perpendicular,  —  whicli  was  as  pathognomonic  as 
if  the  patient  had  an  everted  foot.  There  was  little  or  no 
shortening-,  because  there  was  little  or  no  e version.  But  I 
have  no  doubt  that  it  was  a  case  of  impacted  fracture. 

A  third  patient,  thirty-eight  years  old,  fell  a  distance  of  five 
feet  upon  his  right  hip.  There  were  the  usual  pain  and  ten- 
derness over  the  great  trochanter.  The  disability  was  not 
very  great ;  he  could  move  his  limb.  The  eversion  was  only 
shown  by  the  absence  of  power  to  invert.  There  was  little 
or  no  shortening,  and  no  crepitus.  You  will  anticipate  me  in 
the  diagnosis. 

We  may  contrast  these  cases  with  another,  —  a  male  pa- 
tient, sixty-one  years  of  age,  whom  you  saw  in  the  large  ward. 
There  was  well-marked  crepitus ;  the  shortening  was  nearly 
an  inch,  and  the  eversion  was  very  pronounced.  Here  the 
injury  was  doubtless  a  fracture  of  the  small  part  of  the  neck 
of  the  bone,  leaving  only  a  doubt  whether  it  was  not  originally 
an  impacted  fracture  in  which  the  fragments  had  been  de- 
tached and  drawn  apart  by  unjustifiable  examination, — 
which  is  a  matter  we  shall  come  to. 

So  that  the  point  important  to  remember  is,  when  a  pa- 
tient meets  with  an  injury,  however  slight,  about  the  hip, 
as  indicated  by  pain  and  disability  there,  and  upon  examina- 
tion has  no  crepitus,  next  to  no  shortening,  and  but  little 
apparent  eversion,  and  you  ask  yourself.  Is  this  only  a 
sprain  ;  can  he  have  a  fracture  of  the  hip  ?  —  the  answer  is, 
Unquestionably  he  can.  He  may  have  a  very  slight  impac- 
tion of  the  base  of  the  neck  into  the  base  of  the  trochanter, 
which  may  disable  him  for  two  or  three  months,  which  may 
heal  without  difficulty,  and  leave  little  or  no  traces  in  the 
bone  of  its  existence ;  or,  on  the  other  hand,  the  impaction 
may  be  such  —  the  parts  so  firmly  locked  together  —  that 
if  you  had  the  specimen  in  your  hands,  you  could  not  draw 
the  neck  of  the  bone  out  of  the  trochanters.     Do  not  for- 


182       FRACTURE   OF  THE   NECK   OF   THE   THIGH-BONE. 

get,  however,  that  it  may  be  quite  the  reverse  when  you 
resort  to  the  powerful  leverage  of  the  bent  leg  held  at  the 
knee  and  ankle  in  a  futile  search  for  crepitus.  You  may 
then  twist  the  fragments  apart,  doing  the  patient  a  serious 
damage,  which  he  would  have  escaped  had  you  been  more 
familiar  with  the  signs  of  the  accident  and  avoided  an  un- 
necessary examination. 

The  impaction  of  its  base  being  the  most  frequent  accident 
to  the  neck  of  the  femur,  there  is,  on  the  other  hand,  an  im- 
paction at  the  other  end  of  the  neck,  which,  so  far  as  speci- 
mens testify,  is  very  rare  ;  namely,  that  in  which  the  neck  is 
driven  into  the  head.  An  illustration  of  this  is  seen  in  a 
specimen  I  show  you  from  a  case  of  the  late  Dr.  Gay,  ob- 
tained from  a  patient  who  died  in  the  hospital, — a  case  I  have 
mentioned  in  my  paper  on  this  subject.  This  man  slipped 
at  the  foot  of  his  steps  on  the  sidewalk,  but  nevertheless  got 
into  his  door,  climbed  one  flight  of  stairs,  went  to  bed  without 
assistance,  and  only  sent  for  Dr.  Gay  on  the  next  day.  He 
was  removed  to  the  hospital,  where  about  ten  days  after  he 
died  of  pneumonia.  A  few  hours  before  his  death  he  said, 
"  Doctor,  I  am  getting  along  well  with  my  leg,"  lifting  it  off 
the  bed,  without  help,  to  justify  the  assertion.  There  is  no 
reason  why  he  should  not  have  been  able  to  lift  his  broken 
leg  if  the  parts  were  firmly  impacted.  A  man  can  walk  with 
a  dislocated  hip  where  the  bone  is  firmly  supported  by  the 
ligaments,  and  he  can  also  sometimes  bear  weight  on  the 
common  impacted  fracture.  In  this  case  the  fact  of  the  frac- 
ture was  established  by  the  specimen.  The  neck  was  driven 
into  the  head,  and  the  head  was  bent  backward  toward  the 
trochanter  minor,  —  which  I  believe  to  be  the  rule,  although 
a  case  is  recorded  where  the  head  was  tilted  a  little  the  other 
way.  In  this  remarkable  and  interesting  case,  cited  by  Pirrie,^ 
the  limb  was  flexed  and  inverted  across  the  abdomen,  as  in  the 

1  The  Lancet,  1879,  p.  5. 


FEACTURE  OF  THE  NECK  OF  THE  THIGH-BONE.    183 

first  stage  of  dorsal  dislocation.  Here  the  capsular  ligament 
proved  to  be  sound ;  and  it  probably  aided  in  maintaining 
the  deformity,  the  neck  being  broken  near  the  head.  These 
cases  explain  others.  Dr.  Gushing,  of  Dorchester,  had  a  pa- 
tient, an  elderly  lady,  who  fell  while  winding  up  a  clock.  He 
wa^  sure  from  all  the  signs  that  she  had  a  fracture  of  the 
neck  of  the  thigh-bone.  She  lived  a  number  of  years,  and 
got  about,  walking  pretty  well.  The  articulating  surface,  as 
you  see,  was  broken  off  like  a  watch  crystal,  tilted  back,  as 
in  Dr.  Gay's  case,  and  united  by  bone  in  its  new  position. 
We  have  a  third  specimen  of  this  same  sort. 

This  last  named  fracture,  far  rarer  than  the  impaction  of 
the  base,  cannot  be  distinguished  from  it.  Indeed,  there  is  no 
advantage  in  making  such  a  distinction.  If  a  patient  has  an 
impaction  of  the  neck  of  the  bone  you  need  not  know  any 
more ;  the  chances  are  that  he  will  have  bony  union.  I 
believe  that  all  the  specimens  of  bony  union  of  the  neck  of 
the  thigh-bone  within  the  capsular  ligament  —  as  they  were 
called  in  old  times  —  are  cases  where  the  summit  of  the  neck 
was  impacted  into  the  head  of  the  bone,  and  the  parts  were 
fixed  and  at  rest.  If  mobility  is  one  great  obstacle  to  union, 
it  should  follow  that  where  the  fragments  are  kept  at  rest  by 
impaction  there  will  be  a  tendency  to  union ;  and  we  find  this 
to  be  the  fact. 

In  corroboration  of  this  you  will  observe  that  in  the  vertical 
section  of  almost  all  specimens  of  intra-capsular  fracture  with 
osseous  union,  such  as  the  books  usually  figure,  there  is  a 
dense  white  line  of  bone.  This  is  the  posterior  wall  of  the 
lower  fragment  imbedded  in  new  material,  and  is  usually 
long  enough  to  show  that  the  fracture  was  at  the  upper  part 
of  the  neck. 

Here,  then,  are  three  lesions,  —  the  most  common  being  the 
impacted  fracture  of  the  base  of  the  neck ;  the  least  common 
the  impacted  fracture  of  the  other  end  of  the  neck,  which 


184       FRACTURE   OF  THE   NECK  OF  THE   THIGH-BONE. 

need  not  and  cannot  be  distinguished  from  it ;  the  third  and 
familiar  one  being  the  fracture  at  the  small  part  of  the  neck, 
—  the  fracture  of  old  people. 

Let  me  now  suppose  another  state  of  things.  I  have  said 
that  the  impacted  fracture  of  the  base  of  the  neck  is  attended 
with  eversion,  due  to  the  bending  of  the  neck  upon  an  anterior 
hinge.  Let  us  suppose  that  impaction  has  been  so  great  that 
the  neck  is  displaced  from  this  hinge,  and  driven  squarely  in 
between  the  walls  of  the  trochanter.  When  this  happens  the 
whole  inter-trochanteric  mass,  including  the  greater  and  the 
lesser  trochanter,  is  split  off.  The  anterior  hinge  no  longer 
exists.  There  is  no  longer  any  cause  for  eversion,  and  there 
may  be  actual  inversion  instead  of  the  usual  eversion.  This 
injury  is  a  rare  one. 

A  subject  in  the  dissecting-room  was  transferred  to  me  a 
dozen  years  ago  as  a  case  of  unreduced  dislocation  upon  the 
dorsum,  the  knee  being  greatly  inverted.  Upon  examination 
I  found  that  instead  of  a  dislocation  there  was  an  impacted 
fracture  of  the  neck,  with  inversion.  In  this  instance  the  neck 
had  penetrated  between  the  anterior  and  the  posterior  walls 
of  the  inter-trochanteric  mass,  splitting  them  apart,  and  had 
finally  united,  presenting  a  specimen  of  the  very  rare  fracture 
of  impaction  of  the  neck  with  inversion.  I  have  seen  very 
few  such  specimens,  and  I  have  looked  over  many  museums. 
Smith,  of  Dublin,  mentions  their  exceptional  occurrence. 

It  only  remains  for  us  to  consider  the  group  of  fractures 
that  occur  about  the  head  of  the  shaft.  We  may  class  them 
together  as  fractures  of  the  trochanters. 

There  is  here  no  rule  for  the  position  of  the  limb.  It  is 
generally  everted.  There  is  no  rule  for  the  line  of  the  frac- 
ture, nor  advantage  in  knowing  it ;  there  is  no  limit  to  the 
extent  of  the  comminution.  The  neck  of  the  bone  may  lie 
transversely  instead  of  obliquely,  and  may  be  displaced  so 
far  outward   that   it  becomes  united   by  its   middle   to   the 


FRACTURE   OF  THE   NECK   OF   THE   THIGH-BONE.         185 

shaft,  as  in  the  letter  T,  and  the  femur  looks  like  the  handle 
of  an  old  man's  cane.  Of  course  you  get  crepitus;  you 
find  a  certain  mobility ;  you  detect  shortening,  and  in  its 
treatment  you  would  instinctively  draw  the  limb  down  and 
keep  it  there. 

I  cannot  see  how  you  should  mistake  such  a  loose  fracture 
for  an  impacted  fracture.  But  you  might  mistake  it  for  frac- 
ture of  the  middle  part  of  the  neck,  —  fracture  of  old  people, 
—  and  so  err,  not  in  treatment,  but  in  prognosis ;  inasmuch 
as  the  former  usually  unites  by  bone,  —  the  latter,  so  far  as 
I  know,  never. 

And  now  as  regards  treatment  and  its  results.  If  the  injury 
is  not  a  dislocation,  —  which  you  ought  to  be  able  to  deter- 
mine, —  you  can  do  nothing  better  than  to  draw  the  limb  down 
and  keep  it  steady.  But  if  there  is  no  great  shortening,  —  as 
in  the  case  of  an  impacted  fracture,  —  then  obviously  you  need 
not  draw  the  limb  down,  because  it  is  not  much  drawn  up. 
In  fact,  if  you  try  to  draw  it  down  you  may  do  great  damage 
by  separating  the  impacted  fragments.  So  that  the  treatment 
reduces  itself  to  a  very  simple  matter.  If  there  is  much 
shortening  and  mobility,  draw  the  limb  down,  correcting  as 
far  as  you  can  the  usual  tendency  to  eversion ;  if  not,  only 
steady  it. 

I  again  repeat,  in  impacted  fracture  you  should  be  careful 
not  to  draw  or  twist  the  fragments  apart.  You  saw  the  case 
in  the  wards  where  a  surgeon  had  probably  detached  the  frag- 
ments, and  I  have  said  that  you  get  great  leverage  by  taking 
hold  of  the  ankle  and  the  bent  knee.  In  this  way  you  can 
almost  break  a  sound  bone.  No  surgeon  is  justified  in  twist- 
ing such  an  injured  limb  about  —  especially  if,  employing 
ether,  he  is  unrestricted  by  the  pain  he  gives  the  patient  — 
in  persistent  attempts  to  get  crepitus.  Much  less  is  it  desir- 
able that  a  number  of  surgeons,  one  after  the  other,  should 
do  so. 


186        FRACTUKE   OF   THE   NECK   OF  THE   THIGH-BONE. 

In  a  person  of  an  age  liable  to  "  the  fracture  of  old  people," 
great  shortening,  eversion,  and  mobility  usually  mean  fracture 
of  the  middle  of  the  neck,  and  you  can  say  to  the  patient, 
"  You  will  probably  be  lame ; "  and  yet  a  case  of  this  sort 
occasionally  happens  which  you  cannot  distinguish  from  one 
of  fracture  of  the  trochanters,  likely  to  result  in  bony  union 
with  some  lameness,  —  perhaps  only  that  which  follows  from  a 
shortening  which  the  spine  cannot  compensate,  or  from  bony 
callus  about  the  joint.  Late  in  life  shortening  of  the  femur 
is  not,  however,  readily  corrected  by  a  spinal  curve.  In  a 
robust  or  young  subject  a  fracture  about  the  head  of  the  bone, 
not  attended  with  great  shortening  or  eversion,  is  probably 
impacted,  and  will  in  all  likelihood  unite  by  bone,  leaving  the 
patient  not  very  lame.  An  inch  and  a  half  shortening  after 
a  fracture  in  the  region  under  consideration  is  no  great  mat- 
ter ;  a  man  may  walk  nearly  as  well  with  it  as  without  it. 
After  a  while  the  pelvis  tilts,  and  you  may  not  be  able  to 
determine  by  tlie  gait  which  limb  is  the  shortest. 

I  have  just  intimated  that  a  comminuted  fracture  of  the 
trochanters  sometimes  leaves  a  mass  of  bony  callus,  produc- 
tive of  lameness ;  and  as  this  fracture  cannot  always  be  dis- 
tinguished from  loose  fracture  of  the  small  part  of  the  neck 
by  any  justifiable  examination,  it  is  safest,  where  there  is 
much  shortening,  eversion,  and  mobility,  to  give  a  guarded 
prognosis.  If  the  patient  ultimately  walks  better  than  you 
predicted,  he  will  not  object. 

You  should  always  see  that  an  effort  is  made  to  correct 
eversion  in  every  case  of  fractured  femur.  I  do  not  know 
any  more  effective  means  to  this  end  than  long  sandbags 
packed  under  the  trochanter  from  the  outset,  —  in  fact,  out- 
side the  whole  limb ;  indeed,  you  had  better  put  sandbags  on 
both  sides  of  it.  And  you  must  watch  the  patient,  who  is 
always  trying  to  ease  his  limb.  The  patella  and  the  great 
toe  should  look  directly  upward.      A  sole-piece  and  splint 


FRACTUKE   OF  THE  NECK  OF   THE   THIGH-BONE.        187 

may  be  attached  to  the  foot  and  leg,  which  can  so  be  kept 
vertical. 

Extension,  whether  for  the  purpose  of  drawing  down  a 
loose  fracture  or  of  merely  steadying  an  impacted  one,  is 
best  applied  by  the  familiar  expedient  of  adhesive  straps,  a 
pulley,  and  a  weight  of  five  to  eight  pounds,  upon  a  bed 
without  a  foot-board,  —  its  lower  end  being  raised  six  inches, 
if  necessary,  to  secure  counter-extension. 


PART  II. 

EAPID    LITHOTKITY,    WITH 
EVACUATION. 


KAPID   LITHOTRITY. 


When  Sydney  Smith  asked,  "  What  human  plan,  device,  or 
invention  two  hundred  and  seventy  years  old  does  not  require 
reconsideration  ? "  he  would  no  doubt  have  regarded  with 
favor  an  occasional  reconsideration  of  the  theory  and  practice 
of  medicine  and  surgery,  —  especially  in  view  of  the  current 
belief  that  their  traditions  had  been  kept  alive  and  their 
rules  prescribed  in  part  by  authority.  The  surgical  literature 
of  Lithotomy,  both  French  and  English,  so  long  showed  the 
influence  of  the  early  specialists,  that  we  have  hardly  now 
escaped  from  its  exaggerated  circumstance  and  detail ;  and 
yet,  with  attention  to  a  few  precise  rules,  the  operation  of 
lithotomy  is  quite  a  simple  one,  —  much  less  difficult',  for 
example,  than  the  dissection  of  tumors.  It  is  not  impossi- 
ble that  convictions  in  some  degree  traditionary  may  prevail 
in  regard  to  certain  points  connected  with  the  practice  of  the 
more  recent  art  of  Lithotrity. 

Civiale  was  among  the  first  to  inculcate  the  excessive  sus- 
ceptibility of  the  bladder  under  instruments.  Later  surgeons, 
perhaps  influenced  in  part  by  his  teaching,  have  continued 
to  invest  the  operation  of  lithotrity  with  precautions  which 
though  by  no  means  groundless,  because  under  certain  condi- 
tions both  the  bladder  and  urethra  actively  resent  even  slight 
interference,  are  nevertheless  greater  than  this  operation  gen- 
erally requires.  As  a  rule,  there  is  little  mechanical  difficulty 
in  its  performance.  The  stone  is  readily  caught  and  broken 
into  fragments,  of  which  a  few  are  pulverized ;  a  large-eyed 
catheter  is  then  sometimes  introduced;  a  little  sand  and  a 


192  KAPID   LITHOTRITY. 

few  bits  of  stone  are  washed  out ;  after  which  the  patient  is 
kept  quiet,  to  discharge  the  remainder  and  to  await  another 
"  sitting."  Under  favorable  circumstances  such  an  opera- 
tion, lasting  a  few  minutes,  is  not  only  simple,  but,  if  skil- 
fully performed,  safe. 

On  the  other  hand,  it  is  not  always  safe.  This  is  the  fact 
that  seems  to  have  arrested  so  strongly  the  attention  of 
surgeons.  It  may  happen  that  during  the  night  succeeding 
the  operation  the  patient  has  a  chill,  —  not  the  chill  of  so- 
called  "  urethral  fever,"  which  sometimes  follows  the  mere 
passage  of  a  bougie,  and  which  is  of  little  consequence ;  but 
one  followed  by  other  symptoms,  such  as  tenderness  in  the  re- 
gion of  the  bladder,  a  quickened  pulse,  an  increasing  temper- 
ature, and  the  frequent  and  painful  passage  of  urine.  These 
symptoms  may  insidiously  persist  rather  than  abate.  Others 
may  supervene.  The  surgeon  vainly  waits  for  a  favorable 
moment  to  repeat  his  operation ;  it  becomes  too  evident  that 
the  patient  is  seriously  ill,  and  it  is  quite  within  the  range 
of  possibilities  that  in  the  course  of  days  or  weeks  he  may 
quietly  succumb.  An  autopsy  discloses  a  variety  of  lesions, 
some  of  them  remote  or  obscure,  others  of  more  obvious 
origin, —  and  among  them,  not  the  least  common,  an  inflamed 
bladder,  upon  the  floor  of  which  angular  fragments  and  chips 
of  stone  are  resting.  It  is  then  evident  that  during  a  certain 
interval  before  death  the  bladder  was  not  in  a  condition  for 
further  instrumental  interference;  and  although,  in  view  of 
the  fatal  result  of  delay,  lithotomy  or  active  lithotrity,  to  both 
of  which  I  have  resorted,  might  have  been  deemed  on  the 
whole  the  less  dangerous,  still  it  is  plain  that  either  operation 
would  have  furnished  in  itself  an  additional  cause  of  progres- 
sive inflammation. 

Such  cases  have  been  supposed  to  point  to  the  necessity 
of  extreme  precaution,  as  well  as  of  extreme  remedies.  It  is 
evident  that  the  purpose  of  interference   at   an   unfavorable 


RAPID  LITHOTRITY.  193 

moment  is  the  removal  of  the  offending  fragments  as  a 
last  resource.  But  if  at  the  first  operation  the  bladder  could 
have  been  completely  disembarrassed  of  every  particle  of 
stone,  even  with  the  risk  of  irritating  its  lining  membrane,  we 
can  hardly  doubt  that  the  relief  would  then  have  been  fol- 
lowed by  comparatively  ready  repair.  In  short,  it  is  difficult 
to  avoid  the  conviction  that  in  an  average  case  damage  to  the 
mucous  membrane  is  as  likely  to  result  from  irritation  by 
angular  fragments,  added  to  the  injury  inflicted  by  an  opera- 
tion, as  from  the  use  of  instruments  protracted  beyond  the 
usual  time  for  the  entire  removal  of  a  stone,  if  this  result  can 
be  accomplished. 

It  is  probable  that  injury  from  the  use  of  instruments  has 
been  confounded  with  that  resulting  from  the  presence  of  frag- 
ments in  the  bladder.  That  the  average  bladder  and  urethra 
have  no  extreme  susceptibility  is  attested  by  the  generally 
favorable  results  of  lithotrity,  and  even  of  catheterism,  which 
are  practised  with  very  varying  skill  everywhere  ;  also  by  the 
singularly  innocuous  results  of  laceration  of  the  contracted 
urethra,  by  an  instrument  like  that  of  Yoillemier,  for  example; 
so,  too,  by  the  recovery  of  these  organs  from  the  considerable 
injury  inflicted  during  the  extraction  of  a  large  and  rough  stone 
in  lithotomy.  The  bladder  is  often  also  to  an  extraordinary 
degree  tolerant  of  the  presence  even  of  a  mulberry  calculus. 
If  we  remember  that  in  this  case  it  clasps  the  stone  at  every 
micturition,  often  with  a  persistent  gripe,  the  comparative 
immunity  of  its  tender  mucous  membrane  is  quite  remarkable. 
But  when  after  an  operation  sharp  fragments  are  thus  em- 
braced, presenting  acute  angles,  which  do  not  soon  become 
blunted,  and  to  which  the  bladder  is  unaccustomed,  it  is  still 
more  remarkable  that  serious  consequences  are  the  exception 
and  not  the  rule  in  lithotrity.  Polished  metallic  surfaces 
carefully  manipulated  can  hardly  do  such  damage  as  the  other 
agencies  here  mentioned. 

13 


194  RAPID   LITHOTRITY. 

Gentleness,  dexterity,  and  experience  are  especially  to  be 
valued  in  lithotrity.  If  the  bladder  is  pinched,  the  patient 
may  die.  A  false  passage  or  a  lacerated  inner  meatus  is  a 
serious  complication.  It  has  been  well  said  that  no  novice 
should  undertake  this  operation.  Civiale,  with  an  almost  un- 
paralleled experience,  introduced  a  small  lithotrite  with  much 
less  pressure  than  its  own  weight,  and  with  uniform  and  great 
slowness  ;  and  yet  in  a  healthy  urethra  it  is  only  at  the  tri- 
angular ligament  and  beyond  it  that  such  extreme  care  is 
called  for.  The  same  author,  who  had  no  means  of  evacuating 
fragments  in  the  bladder,  restricted  the  length  of  his  operation 
to  two  or  three  or  perhaps  five  minutes.  The  like  solicitude 
seems  to  have  led  Sir  Henry  Thompson,  in  his  admirable  and 
standard  work  upon  this  subject,  to  assign  two  minutes  as  the 
proper  average  duration  of  a  sitting,  —  a  period  which  his 
exceptional  skill  has  often  in  his  own  practice  enabled  him 
materially  to  reduce.  I  have  been  gratified  to  find,  however, 
that  since  he  has  availed  himself  of  the  advantage  of  etheriza- 
tion he  recognizes  the  benefit  to  be  derived  from  somewhat 
more  prolonged  manipulation.  My  own  conviction  is  that  it  is 
better  to  protract  the  operation  indefinitely  in  point  of  time, 
if  thus  the  whole  stone  can  be  removed  without  serious  injury 
to  the  bladder.  I  believe  that  in  any  case  as  favorable  to 
lithotrity  as  the  average,  in  these  days  when  stones  are  de- 
tected early,  this  can  be  effected, — and  tliat  if  the  bladder  be 
completely  emptied  of  detritus,  we  have  as  little  to  apprehend 
from  the  fatigue  of  the  organ  consequent  upon  such  manipula- 
tion as  from  the  alternative  of  residual  fragments  and  further 
operations.  The  duration  of  the  longest  sitting  among  the 
cases  reported  at  the  end  of  this  paper  was  three  hours  and 
three  quarters.  The  same  result  can  be  now  accomplished 
in  a  very  much  shorter  time.  In  a  majority  of  cases  the 
bladder  can  be  completely  and  at  once  evacuated. 

But  has  not  this  result  been  already  attained  by  evacuating 


RAPIIJ   LITHOTRITY.  195 

instruments  variously  devised  and  modified  ?  The  following 
quotations  from  the  latest  authorities  sufficiently  answer  this 
question  in  the  negative  :  — 

"We  may  here  say,  without  fear  of  being  accused  of  exag- 
geration, that  evacuating  injections  j^ractised  after  sittings  of 
lithotrity  have  no  apology  for  their  use.  The  whole  surgical  arse- 
nal invented  for  their  performance  is  absolutely  useless.  .  .  .  It 
should  be  tvell  understood  that  the  best  of  evacuating  catheters  is 
worthless. ^^  ^ 

'■'■The  practice  of  injecting  the  bladder  to  xoash  out  detritus  is 
obsolete.  .  .  .  This  ajiparatus  of  Mr.  Clover  should  not  be  em- 
ployed if  it  is  2)ossible  to  dispiense  tvith  it,  as  its  use  is  quite  as 
irritating  as  lithotrity  itself."^ 

''Having  used  it  [Clover's  api^aratus]  very  frequently,  I  would 
add  that  it  is  necessary  to  use  all  such  apparatus  with  extreme 
gentleness,    and  /  ^9?'e/er  to   do  ivithout  it  if  possible.^^  ^ 

"  All  these  evacuating  catheters  are  little  employed.  They 
require  frequent  and  long  manoeuvres,  which  are  not  exempt 
from  dangers  ;  besides,  they  give  passage,  as  a  rule,  only  to  dust, 
or  to  little  fragments  of  stone,  ivhich  xoould  have  escaped  of  them,- 
selves  without  inconvenience  to  the  urethra.''''  '^ 

M.  Voillemier  here  states  the  precise  difficulty.  The 
"  evacuating  apparatus  "  and  the  evacuating  method  hitherto 
•employed  do  not  evacuate.     This  fact  is  beyond  question. 

Such  apparatus  is  not  of  recent  contrivance.  From  the 
•earlier  days  of  lithotrity,  the  operation  of  breaking  the  stone 
has  been  followed  by  the  obvious  expedient  of  introducing  a 
large  and  special  catheter,  through  which  water  was  injected 
and  allowed  to  escape,  bringing  away  a  little   sand,  with  a 

1  Article  Lithotritie,  by  Demarquay  et  Cousin,  in  the  Nouveau  Dic- 
tionnaire  de  Medecine  et  de  Chirurgie  Pratique,  pp.  693,  694.    Paris,  187.5. 

2  S.  D.  Gross:  Diseases,  etc.,  of  the  Urinary  Organs,  p.  232.  Phila- 
delphia, 1876. 

8  Sir  H.  Thompson  :  Practical  Lithotrity  and  Lithotomy,  p.  215.  1871. 
*  Article  Lithotritie,  by  M.  Voillemier,  Dictionnaire  Encyclopedique 
■des  Sciences  Medicales,  p.  733.     1869. 


196  KAPID  LITHOTKITY. 

small  fragment  or  two.  This  attempt  at  evacuation  was  aided 
by  suction.  With  this  object,  and  before  the  year  1846,  Sir 
Philip  Crampton  employed  an  exhausted  glass  globe. ^  For 
the  same  purpose  a  rubber  enema-syringe  has  been  used,  or 
a  hydrocele  bottle,  with  which  fluid  could  also  be  injected  and 
the  bladder  washed.  By  entering  the  catheter  well  within 
the  bottle,  or  syringe,  fragments  were  dropped  inside  the  neck, 
where,  lying  below  the  current,  they  remained  when  the  bottle 
was  again  compressed.  When  this  neck  was  made  of  glass 
by  Clover,  the  fragments  became  visible,  as  in  Crampton's 
globe  ;  and  to  this  neat  arrangement  the  accomplished  litho- 
tritist.  Sir  Henry  Thompson,  refers  as  Clover's  bottle.  But 
neither  the  previous  practice  nor  the  efficiency  of  evacuation 
by  suction  through  a  tube  had  been  materially  advanced.  In 
the  mean  time  the  syringe  was  modified  in  France  by  a  rack 
and  pinion  attached  to  the  piston,  so  that  water  could  be 
injected  and  withdrawn  with  great  force,  —  a  procedure  not 
only  useless,  but  detrimental  to  the  bladder,  if  inflamed  and 
thickened. 

Before  describing  my  own  instruments,  it  may  be  well  to 
say  a  word  in  regard  to  the  introduction  of  large  instruments 

1  The  apparatus  here  aUuded  to  was  intended  more  particularly  "  for 
clearing  the  bladder  of  detritus,  in  cases  in  which  the  expulsive  power 
of  that  organ  has  been,  as  so  frequently  happens  in  old  persons,  im- 
paired or  destroyed."  In  Sir  Philip's  own  words  :  "  The  apparatus  con- 
sists of  a  strong  glass  vessel  of  an  oval  form  and  six  or  eight  inches  in 
length  by  three  in  diameter,  and  capable  of  holding  about  a  pint  and 
a  half  of  water ;  to  this  vessel  is  attached  a  tube  of  about  half  an  inch 
bore,  furnished  with  a  stop-cock.  The  air  being  exhausted  by  means 
of  an  exhausting  syringe,  and  one  of  Heurteloup's  wide-eyed  steel  evacu- 
ating catheters  being  introduced  into  the  bladder,  it  is  next  attached  to 
the  exhausted  vessel ;  the  stop-cock  is  then  turned,  and  a  communication 
being  thus  established  between  the  bladder  and  the  glass,  the  pressure  of 
the  atmosphere  is  by  this  means  brought  to  bear  on  the  bladder,  and 
supplies  an  expulsive  power,  which  may  be  increased  to  any  required 
amount."  —  The  Dublin  Quarterly  Journal  of  Medical  Science,  vol.  i. 
p.  22.     1846. 


RAPID   LITHOTRITY.  197 

into  the  bladder.  The  successful  introduction  of  the  large 
straight  tube  is  so  important  that  it  deserves  especial  mention. 
It  throws  light  upon  the  successful  passage  of  the  lithotrite, 
and  also  of  the  large-sized  curved  tubes. 

Urethra  to  he  measured.  —  In  order  to  ascertain  the  maxi- 
mum calibre  of  the  urethra  before  introducing  a  tube,  it  should 
be  measured  by  an  instrument  which  will  enter  more  readily 
than  the  tube.  Such  instruments  we  have  in  Van  Buren's 
Sounds,  which  are  slightly  curved  at  the  end  and  a  little 
conical.  Being  made  of  solid  metal  and  nickel-plated,  they 
traverse  the  urethra  with  singular  facility.  Both  Otis's 
Sounds  and  the  conical  probe-pointed  elastic  bougie  also  an- 
swer admirably  for  this  purpose. 

How  to  pass  a  straight  instrument  into  the  bladder.  —  A 
syringe  facilitates  the  copious  use  of  oil  both  in  the  urethra 
and  within  the  tube.  Into  the  normal  urethra  a  straight 
instrument  can  be  introduced  with  more  accuracy  than  a 
curved  one.  Either  may  be  passed  rapidly  as  far  as  the  tri- 
angular ligament,  unless  the  instrument  is  very  large,  in  which 
case  great  care  is  required  not  to  rupture  the  mucous  mem- 
brane. Having  reached  this  point,  which  implies  that  there 
should  be  no  premature  endeavor  to  turn  the  instrument,  but 
that  it  should  be  passed  as  far  as  it  will  go  in  the  general 
direction  of  the  anus  before  its  direction  is  changed,  the  ex- 
tremity of  the  instrument  depresses  the  floor  of  the  urethra 
in  front  of  the  ligament. 

How  to  pass  the  triangular  ligament. —  Traction  upon  the 
penis  next  effaces  this  depression,  and  adds  firmness  to  the 
urethral  walls  ;  so  that  if  the  instrument  be  withdrawn  a 
little,  and  again  advanced  after  lowering  the  handle  until  it  is 
almost  horizontal,  it  can  be  coaxed  without  difficulty  through 
the  ligament  in  question,  —  a  natural  obstruction  which  phy- 
sicians often  mistake  for  a  stricture.  The  straight  tube  may 
be  advantageously  rotated  through  the  aperture  like  a  cork- 


198  RAPID   LITHOTRITY. 

screw.  This  obstruction  passed,  the  rest  of  the  canal  is  short, 
and  corresponds  to  the  axis  of  the  body,  to  the  line  of  which 
the  instrument  is  now  depressed. 

Presence  of  an  enlarged  prostate. — Even  the  enlarged  pros- 
tate can  often  be  traversed  with  facility  by  a  straight  instru- 
ment. In  fact,  the  metallic  prostatic  catheter,  before  it  was 
superseded  by  the  modern  rubber  one,  consisted  essentially  of 
an  inch  or  two  of  straighter  tube  added  to  the  extremity  of  a 
common  catheter,  to  reach  through  the  unyielding  prostate 
before  the  hand  was  depressed  and  the  beak  turned  up. 

Obstruction  hy  Jissnre  in  the  prostate.  —  An  occasional  diffi- 
culty in  passing  the  enlarged  prostate  deserves  mention  here ; 
namely,  that  resulting  from  a  series  of  cracks  or  fissures,  hav- 
ing their  apex  at  the  verumontanum,  and  radiating  toward 
the  bladder.  I  have  a  specimen  of  large  prostate  where  these 
fissures  readily  engage  a  medium-sized  catheter. 

In  such  a  case  a  large  instrument  may  pass  more  readily 
than  a  small  one.  The  finger  in  the  rectum  is  liere  also  of 
especial  service.  The  handle  of  the  tube  may  be  also  lowered 
to  tilt  up  the  tip  in  passing  the  inner  meatus. 

Obstruction  at  the  inner  meatus.  —  In  passing  either  a 
sound,  catheter,  or  lithotrite,  the  extremity  of  a  straight 
instrument,  and  curiously  enough  the  convexity  of  a  curved 
one,  is  sometimes  arrested  just  at  the  entrance  of  the  bladder 
by  the  firm  lower  edge  of  the  inner  meatus.  The  fact  that 
water  now  dribbles  through  the  inner  meatus  thus  dilated,  or 
that  a  stone  is  felt  with  the  tip  of  the  curved  instrument  which 
has  really  entered  the  bladder,  may  lead  the  operator  into  the 
mistake  of  supposing  that  the  instrument  is  fairly  within ; 
and  I  have  known  its  further  entrance,  after  sliding  over  this 
obstacle,  to  be  erroneously  explained  by  assuming  the  exist- 
ence of  a  second  or  hour-glass  cavity  in  the  bladder  itself. 

How  to  overcome  it.  —  To  obviate  this  difficulty,  and  so 
soon   as   the   triangular   ligament   is   passed,   a   catheter,   if 


RAPID   LITHOTEITY.  199 

curved,  should  be  pressed  fairly  through  the  indurated  neck, 
or  prostate,  in  the  direction  of  the  axis  of  the  body,  by  the 
hand  on  the  perineum,  —  a  most  efficient  manoeuvre  when 
the  prostate  is  large.  If  there  be  further  difficulty,  the  tip 
should  of  course  be  sought  and  guided  in  the  rectum  (see 
p.  206).  After  introduction,  a  straight  tube,  or  the  shaft  of 
a  curved  one,  often  returns  to  an  angle  of  about  45°  with 
the  recumbent  body;  and  if  the  patient  is  not  etherized,  a 
feeling  of  tension  may  then  be  relieved  by  depressing,  with 
the  hand  upon  the  pubes,  the  suspensory  ligament  of  the 
penis,  —  an  expedient  also  useful  during  the  passage  of  the 
instrument. 

Ancesthesia  in  lithotrity .  —  My  own  practice  has  always 
been  to  etherize  for  lithotrity. 

Position  of  the  operator.  —  Each  operator  prefers  the  position 
to  which  he  is  accustomed  ;  and  when  the  urethra  is  healthy, 
this  is  of  very  little  importance.  But  if  there  be  obstruction, 
a  position  at  the  patient's  left  side  enables  the  operator  to  in- 
troduce a  catheter  or  lithotrite  to  advantage  with  the  right 
hand,  leaving  the  left  hand  free  to  act  in  the  perineum. 
After  the  instrument  is  introduced  and  both  hands  are  re- 
quired above  the  pubes,  they  are  most  available  if  the  surgeon 
changes  his  position  and  stands  upon  the  patient's  right.  I 
also  introduce  the  straight  tube  on  the  right  side. 

Passage  of  a  lithotrite.  —  The  lithotrite  is  to  be  passed  as  a 
straight  instrument,  and  not  as  a  curved  catheter.  When 
it  reaches  the  triangular  ligament,  the  tip  is  insinuated  into 
its  aperture,  and  then  the  handle  previously  perpendicular,  or 
nearly  so,  is  depressed  to  an  angle  of  about  45°.  In  this  posi- 
tion it  should  remain,  with  but  little  further  depression,  while 
the  blades  are  gently  urged  forward  through  the  prostate. 
The  convexity  of  the  heel  thus  depresses  the  lower  wall  of 
the  canal  as  it  moves  along  and  makes  room.  It  moves  as  a 
boat,  rising  neither  at  prow  nor  stern  (see  Fig.  19,  p.  313). 


200  EAPID  LITHOTRITY. 

Water  to  be  injected  before  crushing.  —  In  injecting  water 
before  using  the  litliotrite,  the  capacity  of  the  bladder  may  be 
estimated  by  the  tension  of  the  urethra  behind  the  point  of 
constriction.  By  attention  to  this  indication  we  prevent  over- 
distention.  In  the  etherized  subject  a  short  pipe  or  nozzle 
suffices  for  introducing  water.  I  have  usually  employed  a 
common  Davidson's  syringe.  An  unetherized  patient  may  for 
a  moment  resist  this  injection  through  a  short  tube,  by  con- 
tracting the  sphincter  of  the  bladder ;  but  this  readily  yields. 
A  distention  by  five  or  six  ounces  suffices.  The  smaller  the 
injection  of  water  the  more  readily,  indeed,  do  crushed  frag- 
ments fall  into  the  blades  of  the  instrument ;  but  unfortu- 
nately so  also  does  the  mucous  membrane.  In  fact,  with  too 
little  fluid  in  the  bladder  the  use  of  a  litliotrite  in  unpractised 
hands  is  attended  with  danger  ;  and  in  a  long  sitting  an  injec- 
tion which  will  separate  the  walls  is  the  only  really  safe  way  of 
keeping  the  bladder  from  between  the  blades.  A  careful  ex- 
amination of  the  action  of  a  litliotrite  through  an  opening  in 
the  summit  of  the  bladder  has  confirmed  me  in  this  opinion, 
which  was  that  of  the  older  writers  on  this  subject.  From 
time  to  time  the  diameter  of  the  collapsing  bladder  should 
be  estimated  by  slowly  opening  the  blades  of  the  litliotrite. 
Water  may  be  introduced  as  often  as  necessary;  but  care 
should  be  taken  to  guard  against  the  serious  injury  to  a  con- 
tracted bladder  which  might  result  from  suddenly  injecting 
the  contents  of  the  syringe  or  aspirating  bottle  when  it  is 
already  distended.  On  the  other  hand,  distention  of  the 
bladder  is  a  common  symptom  of  retention.  When  extreme, 
it  is  often  followed  by  inflammation  and  atony.  But  in  a 
common  case  we  do  not  anticipate  such  serious  results,  even 
when  micturition  has  been  frequent,  and  the  bladder  by  infer- 
ence small.  It  has  occurred  to  me  whether  a  moderate  forced 
distention  might  not  be  of  service  in  certain  cases  of  con- 
tracted bladder,  as  it  is  in  a  permanently  contracted  anus. 


RAPID   LITHOTRITY. 


201 


Water  retained  ly  an  elastic  hand.  —  A  tape  or  an  elastic 
band  wound  lightly  once  or  twice  around  the  penis  near  the 
scrotum  retards  the  escape  of  injected  water,  and  yet  allows 
the  movements  of  the  tube  or  lithotrite. 

The  successful  evacuation  of 
the  bladder  depends  upon  seve- 
ral conditions  both  in  the  appa- 
ratus and  in  its  use,  which  for 
distinctness  may  be  enumerated 
separately. 

1.  A  large  calibre  of  the  evacu- 
ating tube. 

2.  The  shape  of  its  receiving 
extremity. 

3.  Manipulation  of  the  bulb. 

4.  Capacity  of  the  bladder. 

5.  Evacuation  of  the  fragments. 

6.  Immediate  recognition  and 
removal  of  any  obstruction  in  the 
tube. 

1.  A  large  calibre  of  the  evac- 
uating tube. — Whether  or  not  we 
adopt  the  view  of  Otis  that  the 
average  calibre  of  the  normal 
urethra  is  about  33  of  Charriere, 
there  can  be  no  question  that  it  will  admit  a  much  larger 
tube  than  that  commonly  attached  to  either  Clover's  or  the 
French  apparatus.  The  efficiency  of  the  process  of  evacuation 
depends  much  upon  using  the  largest  tube  the  urethra  will 
admit.     This  fact  has  been  stated  by  Sir  Henry  Thompson, 


Fig.  1.1 


1  Evacuating  Apparatus.  1.  Elastic  bulb.  2.  Curved  rubber  tube. 
3.  Curved  evacuating  tube  of  silver.  4.  Straight  evacuating  tube,  which 
is  preferable  to  the  cui'ved  one.  5.  Front  view  of  same.  6.  Glass  recep- 
tacle, with  bayonet  joint  for  debris.     (Tiemann  and  Co.,  Xew  York.) 


202  RAPID  LITHOTRITY. 

but  with  a  different  significance.  He  recommends  for  the 
glass  cylinder  or  trap  which  is  to  admit  this  tube  a  "  perfo- 
ration at  the  end  the  size  of  only  a  No.  14  catheter,"  =  25 
Cliarriere.^  This  perforation  is  too  small;  and  the  tube 
which  is  designed  to  enter  it  is  further  reduced  by  its  collar 
to  the  diameter  of  only  12,  =  21  Charriere.  In  fact,  this 
is  the  calibre  of  the  evacuating  catheters  now  attached  to 
Clover's  instrument,  and  is  of  itself  fatal  to  their  efficiency. 
An  effective  tube  has  a  calibre  of  28  to  31  or  even  32  Char- 
riere, and  the  meatus,  which  is  the  narrowest  part,  may  if 
necessary  be  slit  to  admit  it,  if  the  urethra  is  otherwise  capa- 
cious. Again,  in  the  instrument  as  sometimes  constructed 
by  Weiss  a  joint  is  made  by  inserting  an  upper  tube  into  a 
lower  one,  thus  obstructing  the  calibre  by  a  shoulder.  The 
joints  should  become  larger  as  the  tube  approaches  the  bottle, 
so  that  the  tube  may  deliver  without  difficulty  fragments  of 
its  own  calibre.  Whatever  be  the  size  of  the  catheter,  the 
rubber  tube  with  its  metal  attachments  should  have  a  calibre 
of  at  least  seven  sixteenths  of  an  inch,  =  81  Charriere,  and 
there  should  be  nowhere  any  approach  to  a  shoulder  inside. 

My  evacuating  tubes  are  of  thin  nickel-plated  metal  of  sizes 
27,  28,  29,  30  and  31  jiUere  Charriere,  respectively.  These 
are  the  sizes,  including  also  perhaps  26  and  32,  which  I  have 
designated  as  "  large  "  in  distinction  to  the  calibre  21  of  pre- 
vious apparatus. 

2.  The  shape  of  its  receiving  extremity.  —  The  receiving 
extremity  should  depress  the  bladder  wlien  required  to  do  so, 
and  thus  invite  the  fragments,  while  its  orifice  remains  unob- 
structed by  the  mucous  membrane.  Upon  the  floor  of  the 
bladder  when  not  indented  a  fragment  of  stone  lying  at  the 
distance  of  half  or  even  quarter  of  an  inch  from  the  tube 
extremity  may  not  be  attracted  by  the  usual  exhaust  of  the 
expanding  bottle,  which  requires  that  the  fragment  should 

1  Diseases  of  the  Prostate,  p.  337.     Fourth  edition,  1873. 


EAPID  LITHOTRITY. 


203 


lie  almost  in  contact  with  the  tube.  A  very  slight  obstacle 
impedes  the  entrance  of  a  fragment;  and  this  fact  renders 
inefficient  all  tubes  like  catheters  with  orifices  along  the 
side  or  upper  wall.  The  orifice  of  a  tube  cut  square  is  at 
once  occluded  by  drawing  in  the  vesical  wall,  while  the 
spoon-shaped  beak  of  the  French  instrument,  made  like  the 
female  blade  of  a  lithotrite,  allows  fragments  to  lie  too  far 
from  the  opening  in  the  tube. 

The  best  orifice 
is  at  the  extrem- 
ity, and  is  made 
by  bending  the 
tube  at  a  sharp 
right  angle,  care- 
fully rounding  the 
elbow,  and  then 
cutting  off  the 
bent  branch  close 
to  the  straight 
tube  (Fig. 2 a).  The 
tube  is  then  prac- 
tically straight, 
while  the  orifice, 
which  is    slightly 

oval,  delivers  its  stream  laterally.  The  edge  should  be  thick- 
ened and  rounded  to  slide  smoothly  through  the  urethra;  any 
rim  inside  the  orifice  should  be  masked  by  a  false  floor,  but 
the  calibre  should  be  nowhere  contracted.  If  the  side  walls 
of  this  orifice  be  removed  a  little,  it  gives  an  unguiform  ex- 
tremity to  the  tube,  which  is  advantageous ;  and  in  introduc- 
ing such  a  straight  tube,  this  tip  should  be  insinuated  through 

^  Evacuating  tubes,  with  unguiform  extremity.  a.  Straight  tube. 
h.  Curved  tube.  The  dotted  lines  show  the  false  floor  of  the  extremity. 
The  tubes  are  here  of  a  diameter  31  Charriere.  The  straight  tube  is 
preferable. 


Fig.  2.1 


204 


RAPID  LITHOTRITY. 


the  triangular  ligament  by  rotation.  If  a  couple  of  inches  of 
the  end  of  such  a  tube  be  bent,  it  may  be  inverted  after  intro- 
duction, and  will  bury  itself  in  the  floor  of  the  bladder,  which  it 
depresses,  while  the  orifice  looks  forward  and  is  unobstructed 
(Fig.  2  b')  ;  or  it  may  be  used  as  introduced.  An  effective 
instrument  may  be  made  of  a  straight  tube  cut  square  at  the 
end,  if  a  disk  convex  outwardly,  to  repel  the  bladder,  be 
attached  to  it  at  the  distance  of  a  diameter  from  the  orifice. 
This  was  the  original  of  the  straight  tube  already  described. 
When  such  an  instrument  is  introduced,  the  interval  can  be 
filled  by  a  rod.  Indeed,  the  orifice  of  a  tube  should  be  con- 
trived with  a  view  to  its  introduction.  Too  large  an  orifice 
impairs  the  suction  and  admits  fragments  that 
become  wedged  higher  up.  Whatever  be  added 
to  the  extremity  of  the  tube,  in  order  to  facili- 
tate its  introduction  or  to  repel  the  bladder, 
should  not  prevent  the  orifice  from  lying,  if  re- 
quired, in  the  floor  of  the  bladder  at  the  apex  of 
an  inverted  tunnel. 

3.  3Ia7iipulaf.ion  of  the  bulb.  —  The  bulb,  to- 
gether with  its  tubes,  contains  about  ten  ounces. 
If  compressed  with  one  hand  until  the  sides 
meet,  only  about  five  ounces  are  displaced.  If 
half  compressed  and  then  worked  with  a  shorter 
movement,  about  two  ounces  are  moved  back 
and  forth ;  so  that,  provided  the  tube  itself  be  handled  care- 
fully and  skilfully,  the  bladder  is  not  greatly  disturbed.     The 


N9  3a 


Fig.  .3.1 


1  Tlie  outline  here  given  of  the  orifice  and  extremity  of  the  tubes  I  use 
is  more  correct  than  that  of  Fig.  2.  If  the  straight  tube  be  closed  by  an 
extremity  symmetrically  round  or  ovoid,  to  facilitate  its  introduction,  the 
orifice  a  d  should  have  a  length  but  little  greater  than  the  diameter  a  c 
of  the  tube.  Tlie  curve  of  the  inside  floor  h  is  a  quarter  circle  described 
upon  a  as  a  centre.  The  tube  is  then  proved  by  a  close-fitting  ball  rolled 
through  it  from  a])0ve.  At  a  the  edge  is  a  little  thickened  on  the  outside, 
and  at  d  rounded  to  protect  the  urethra. 


KAPID  LITHOTRITY.  205 

object  of  more  water  is  to  prolong  suction  when  fragments 
are  passing  freely ;  also  occasionally  to  stir  up  the  debris,  and 
especially  to  relieve  obstruction  in  the  tube  when  it  occurs. 
The  best  position  for  the  surgeon  is  at  the  right  hand  of  the 
patient,  resting  his  left  wrist  on  the  pubes  to  steady  the  tube, 
while  the  bulb  is  supported  in  a  stand  on  the  table  between 
the  thighs  (Fig.  4). 

4.  Capacity  of  the  bladder.  —  It  is  desirable,  in  each  case, 
to  form  an  idea  of  the  habitual  capacity  of  the  bladder.  The 
previous  frequency  of  micturition  throws  some  light  upon  it. 
Better  than  this,  the  tension  of  the  urethra  behind  the  elas- 
tic band  is  a  valuable  indication  of  the  fluid  pressure  in  the 
bladder  during  evacuation.  If  the  patient  strains  for  a 
moment,  the  bladder  may  become  very  tense,  and  I  think  it 
then  important  to  let  the  water  escape  through  the  hose 
(see  p.  278).  The  bladder  can  be  immediately  replenished. 
Without  a  hose  this  manoeuvre  is  impossible. 

PROCESS   OP   EVACUATION. 

Quantity  of  tvater  needed  during  evacuation.  — Unless  the 
amount  of  debris  is  very  abundant,  there  should  be  just  enough 
water  in  the  bladder  to  prevent  the  thud,  or  fish-bite,  hereafter 
described  (p.  217).  While  more  than  this  needlessly  scatters 
the  fragments,  a  smaller  amount  allows  the  bladder  to  be  con- 
stantly drawn  into  the  catheter,  giving  rise  to  the  quivering 
sensation  above  alluded  to  as  the  fish-bite.  Nothing  so  facili- 
tates evacuation  as  the  power  exactly  to  regulate  the  amount 
of  water. in  the  bladder  and  apparatus;  and  no  contrivance  so 
well  accomplishes  this  desideratum  as  the  hose. 

5.  Evacuation  of  the  fragments.  —  Evacuation  of  the  frag- 
ments is  quite  an  entertaining  art,  requiring  as  much  skill 
to  accomplish  the  desired  result  in  the  shortest  time  as  does 
the  act  of  crushing.     Dexterity  in  the  process  will  hardly  be 


206 


RAPID   LITHOTRITY. 


acquired  without  practice  outside  the  bladder.^  No  jerk  is 
required  in  pumping.  The  compression  and  expansion  of 
the  bulb  equally  divide  a  second  or  two  of  time.  While  the 
tube  is  held  just  above  the  debris,  the  fragments  should  fall 


Fig.  42 


*  The  bladder  may  be  imitated  by  the  lower  two-thirds  of  an  ox-bladder 
(carbolized  for  cleanliness)  suspended  inside  a  vessel  having  a  mouth  of 
four  or  five  inches  diameter,  to  which  it  is  tied.  The  vessel  should  be 
previously  nearly  filled  with  water.  To  show  the  efficient  action  of 
circular  currents  in  the  closed  bladder,  the  ox-bladder  may  be  tied  to 
the  evacuating  tube,  and  held  before  a  bright  light.  With  a  tin  funnel 
secured  to  the  summit  of  a  human  bladder  (in  situ)  to  aid  in  replacing 
the  fragments,  the  process  of  evacuation  can  be  rapidly  repeated.  Such 
practice  is  very  instructive.  Calculi  may  be  imitated  by  coal  of  varying 
hardness,  or  by  a  bit  of  old  grindstone ;  a  lighter  and  tough  material  for 
crushing,  and  liable  to  impact,  is  the  cheap  compressed  meerschaum. 

2  The  trap  is  here  placed  in  a  stand  upon  the  table.  The  remaining 
fragments  are  few,  and  the  capacious  bladder  is  depressed  to  assemble 
them.  The  operator  stands  on  the  patient's  left,  and  supports  his  right 
hand  firmly  upon  the  pubes.  This  position  is,  on  the  whole,  the  most 
advantageous. 


RAPID   LITHOTRITY. 


207 


in  a  shower  into  the  trap.  The  operation  may  be  divided 
into  a  first  and  a  last  half.  During  the  first  half,  while  the 
fragments  are  numerous,  the  secret  is  to  separate  and  float 
them  by  the  injection,  so  that  they  may  enter  the  tube  as 


they  fall,  in  single  file,  without  obstructing  it. 
This  is  accomplished  by  keeping  the  orifice  of  the 
tube  away  from  the  floor,  aspirating  the  fragments 
quickly  while  on  the  wing,  just  above  the  commi- 
nuted mass.  In  the  latter  part  of  the  process, 
and  after  the  smaller  debris  has  been  removed,  by 
raising  its  outer  extremity  the  tube  may  be  made 
to  indent  the  floor  so  as  to  gather  instead  of  separating  the 


1  The  operator  is  here  supposed  to  sit  between  the  thighs  of  the 
patient.  The  bulb  has  been  compressed,  and  by  its  immediate  expansion 
will  aspirate  a  part  of  the  abundant  debris  suspended  in  the  fluid  above 
the  fragments.  This  Figure  illustrates  the  advantage  of  dispersing  the 
fragments  for  aspiration,  when  too  abundant.  But  the  same  result  can 
be  better  accomplished  by  withdrawing  the  tube  a  little  from  the  floor, 
with  the  hand  supported  on  the  pubes  as  in  Fig.  4.  (From  a  photograph 
of  a  frozen  section,  in  which  the  rectum  and  the  bladder  were  previously 
distended  with  plaster.) 


208  .  KAPID  LITHOTRITY. 

fragments.  Some  of  the  chips  are  apt  to  collect  about  the 
tube  orifice ;  but  the  tube  thus  raised  is  carried  behind  them. 
It  is  important  occasionally  to  turn  the  orifice  forward  to 
wash  the  fragments  from  beneath  the  shoulder  of  a  high 
prostate.  A  very  slight  movement  of  the  tube  sometimes 
makes  much  difference  in  the  rapidity  of  the  evacuation ; 
so  that  when  it  is  on  the  floor  of  the  bladder  or  quite  near 
it,  and  steadied  by  the  hand  upon  the  pubes  or  the  thigh,  if 
any  one  expansion  of  the  bulb  proves  more  successful  than 
another,  the  precise  position  then  occupied  by  the  tube 
should  be  carefully  maintained.  On  the  other  hand,  when 
the  tube  is  choked  at  each  expansion,  if  it  be  withdrawn,  or 
tilted  up  a  quarter  or  even  an  eighth  of  an  inch,  it  may 
happen  that  a  shower  of  debris  at  once  appears  in  the  trap. 
Higher  in  the  cavity,  while  the  debris  is  abundant,  the  orifice 
may  be  turned  downward  or  partly  sideways,  so  as  to  project 
horizontal  currents  around  the  bladder,  the  fragments  being 
aspirated  as  they  whirl.  At  the  different  stages  of  the  pro- 
cess there  is  opportunity  for  a  little  tact  in  placing  the  tube, 
just  as  there  is  in  discovering  fragments  with  a  lithotrite. 

6.  Immediate  recognition  and  removal  of  obstruction  in  the 
tube.  —  If  a  short  interval  elapses  without  the  fall  of  debris, 
it  may  be  presumed  that  there  is  obstruction.  This  happens 
not  only  when  the  bulb  will  not  expand,  when  its  dimple  dis- 
appears reluctantly,  and  when  compression  is  difficult,  but 
also  when  the  current  passes  so  freely  that  an  impediment 
would  hardly  be  suspected.  Obstruction  occurs  in  several 
ways :  — 

(1)  In  the  elastic  tube,  which  may  be  accidentally  bent  at 
an  angle  or  compressed.  This  should  be  looked  at  first.  A 
bit  lodged  in  the  elastic  can  be  displaced  by  pinching  it. 

(2)  In  the  bladder,  the  most  common  obstruction  is  at  the 
orifice  of  the  evacuating  tube.  A  little  practice  will  enable 
the  operator  to  distinguish  the  encouraging  rattle  of  debris 


RAPID  LITHOTEITY.  209 

passing  this  tube  to  appear  at  once  in  the  trap  (if  held 
upright)  from  the  valvular  click  of  fragments  too  large  to 
enter  it.  This  click  is  quite  constant  at  the  end  of  the  pro- 
cess, after  the  smaller  chips  have  been  aspirated  off.  If  the 
orifice  be  choked,  an  effort  should  be  made  to  expel  the  frag- 
ments in  the  ordinary  way, —  first  raising  the  tube  into  clear 
water  above  the  debris,  and  then  compressing  the  bulb  with  a 
short  and  forcible  squeeze.  A  half-dozen  such  efforts  rarely 
fail ;  but  the  rod  may  be  introduced,  if  necessary. 

(3)  It  sometimes  happens  that  nothing  appears  in  the 
trap,  although  the  current  passes  quite  freely  and  the  click 
of  the  abundant  debris  is  still  felt.  A  scale  is  then  wedged 
higher  in  the  evacuating  tube,  which  admits  water  but  ex- 
cludes fragments.  This  is  worth  remembering.  The  rod 
removes  it. 

(4)  A  source  of  obstruction,  and  the  most  common  one,  is 
the  wall  of  the  bladder  when  drawn  against  the  tube  orifice 
with  a  dull  thud,  or  a  rapid  succession  of  jerks  not  unlike  the 
bite  of  a  fish.  It  naturally  interferes  with  the  process,  and 
if  the  patient  has  not  been  etherized  is  painful.  The  tube 
orifice  may  be  moved  to  another  part  of  the  bladder  where 
aspiration  is  more  free.  Perhaps  the  orifice  has  been  acci- 
dentally turned  sideways  ;  it  then  readily  engages  the  floor. 
But  the  usual  explanation  is  that  the  walls  of  the  bladder  are 
slack,  and  more  water  is  needed  to  distend  them.  This  will 
be  further  noticed. 

After  a  dozen  or  more  aspirations  it  may  be  found  that  all 
the  fragments  which  can  pass  the  tube  have  done  so,  and  that 
many  of  them  have  its  full  diameter.  The  passage  of  debris 
has  ceased,  and  the  larger  bits  are  clicking  against  the  cathe- 
ter. The  lithotrite  should  now  again  be  introduced.  When 
no  click  has  been  heard  for  several  minutes  the  bladder  may 
be  considered  as  practically  cleared,  and  the  patient  should 
be  remanded  for  subsequent  examination. 

14 


210  RAPID  LITHOTRITY. 

LiTHOTRiTE  (Fig.  8).  —  It  would  be  plainly  desirable,  if  it 
were  easy,  to  crush  the  whole  stone  before  attempting  to 
evacuate  it ;  but  this  is  rarely  possible.  The  lithotrite  be- 
comes so  choked  with  impacted  debris  that  the  convex  surface 
of  the  mass  prevents  the  engagement  of  other  fragments 
between  its  blades.  The  character  of  this  impaction  varies. 
The  powder  of  some  varieties  of  soft  stone,  compressed  in 
this  way  with  mucus,  is  singularly  hard,  being  scarcely  in- 
dented with  a  sharp  probe.  A  clean  lithotrite  always  works 
to  best  advantage ;  and  the  operator  frequently  withdraws 
the  loaded  instrument  to  evacuate  it,  sometimes  with  fatal 
injury  to  the  neck  of  the  bladder.  It  would  be  obviously 
better  if  the  instrument  could  be  emptied  at  will  within  the 
bladder,  especially  if  we  distinctly  recognize  that  what  can 
be  withdrawn  in  a  litliotrite  would  come  better  through  a 
tube,  and  that  the  province  of  the  lithotrite  should  he  to  pul- 
verize, or  indeed  merely  to  comminute,  and  not  to  evacuate. 
Fergusson's  operation  consisted  largely  in  bringing  away 
the  finer  debris,  a  pinch  at  a  time,  between  the  blades  of 
the  lithotrite.  I  cannot  understand  why,  when  a  tube  is  to 
be  introduced  into  the  urethra  to  distend  and  protect  it,  and 
to  deliver  the  debris  at  once,  such  a  practice  should  still  find 
advocates. 

Although  all  lithotrites  are  made  a  little  loose  for  the  pur- 
pose of  working  out  the  debris,  and  although  I  have  had  one 
constructed  with  an  especial  device  for  this  motion,  I  do  not 
find  it  easy  to  clear  the  female  blade  by  a  lateral  movement 
of  the  male  blade,  chiefly  because  the  impaction  is  so  firm 
that  the  dense  mass,  instead  of  yielding,  twists  the  female 
blade  from  side  to  side.  Nor  does  an  instrument  like  that 
of  Reliquet  fulfil  the  indications.  It  is  like  the  old  fenes- 
trated brise-pierre ;  but,  as  in  the  hrise-pierre,  its  high  sides 
are  an  obstacle  to  the  approach  of  fragments.  The  male 
blade  also  of  Reliquet's  instrument  is  that  of  the  lithoclast, 


RAPID  LITHOTRITY. 


211 


and  we  need  only  close  the  blades  between  the  thumb  and 
finger  to  be  satisfied  of  their  scissor-like  action  upon  the 
bladder.     Lastly,  it  does  impact  badly. 

The   instrument  about   to  be   described   keeps   its   blades 


clear,  and  secures  certain  other  desirable  ends  pertaining  to 
the  lock,  handle,  etc. 

Lock. — The  general  acceptance  of  the  wheel-shaped  handle 
of  Thompson's  instrument  testifies  to  its  convenience  as  a 

1  Figs.  6  and  7,  —  position  of  the  hands  in  holding  and  locking  this 
lithotrite.  Fig.  6,  lithotrite  unlocked ;  Fig.  7,  lithotrite  locked  by  a 
quarter  rotation  of  the  right  wrist. 


212 


RAPID  LITHOTRITY. 


Fk;.  8.1 


hold  for  the  left  hand.  But  it  is  always  a  little 
awkward  to  disengage  the  thumb  of  this  hand, 
or  indeed  of  either  hand,  in  order  to  close  the 
lock  of  a  lithotrite  at  the  critical  moment  of 
grasping  the  stone.  This  objection  I  have  ob- 
viated in  closing  the  lock  by  rotation  of  the  right 
wrist,  without  relaxing  the  grasp  or  displacing 
the  fingers  of  either  hand  (Figs.  6  and  7). 

Wheel.  —  In  a  protracted  sitting  the  wheel  is 
an  inconvenient  handle,  its  chief  merit  being 
that  it  affords  so  insecure  a  grasp  that  the  ope- 
rator is  supposed  to  be  unable,  with  its  pre- 
scribed radius,  to  break  the  blades.  But  in  a 
larger  instrument  these  blades  are  stronger, 
and  a  ball  may  be  substituted  for  the  wheel 
(Fig.  8  a). 

Injecting  Tube.  —  If  the  sitting  be  protracted, 
as  proposed,  the  water  dribbles  away,  and  the 
collapsing  bladder,  especially  if  trabeculated,  is 
liable  to  serious  damage  from  the  lithotrite. 
To  meet  this  difficulty,  the  injection  of  water, 
by  means  of  a  short,  flat  tube  introduced  into 
the  urethra  from  time  to  time  by  the  side  of 
the  lithotrite,  is  a  valuable  resource  in  a  long 
operation. 

Blades.  —  The  blades  of  this  lithotrite  consist 
of  a  shoe,  or  female  blade,  the  sides  of  which  are 
so  low  that  a  fragment  readily  falls  or  slides 
upon  it ;  while  the  male  blade,  or  stamp,  offers 


1  Lithotrite  by  Collin  et  Cie.,  from  a  working  model,  a,  Ball  which 
turns  the  screw,  b,  Revolving  cylinder-handle  attached  to  the  screw- 
guard,  which  also  revolves.  This  guard  consists  of  two  rods,  which  slide 
through  notches  in  the  cap  of  the  lock.  By  their  revolution  the  cylinder- 
handle  turns  the  cap  and  operates  upon  the  lock,  c.  Cap  of  the  lock, 
which  by  its  revolution  wedges  up  the  screws. 


RAPID  LITHOTRITY. 


213 


a  series  of  alternate  triangular  notches  by  whose  inclined 
planes  the  detritus  escapes  laterally,  after  being  crushed 
against  the  floor  and  rim  of  the  shoe.  At  the  heel  of  the 
shoe,  where  most  of  the  stone  is  usually  comminuted,  and 
where  the  impact  is  therefore  greatest,  the  floor  is  high  and 
discharges  itself  laterally,  while  its  customary  slot  (Fig.  9/) 
is  made  to  work  effectively.  It  may  be  unnecessary  to  say 
that  the  female  blade  of  the  common  lithotrite,  when  drawn 
from  a  thin,  flat  plate  as  in  the  French  instrument,  has  a 
disadvantageous  cavity  at  the  heel,  where  the  greatest  im- 
paction occurs  by  gravitation. 

One  of  the  dangers  of 
lithotrity,  which  has  been 
already  emphasized,  is  the 
liability  of  the  bladder  to 
be  nipped  in  the  instrument. 
The  common  lithotrites,even 
the  best,  have  thin  extremi- 
ties which  seize  the  bladder 
like  forceps.  I  have  known 
a  strip  of  mucous  membrane 
brought  away  in  the  instru- 
ment from  the  floor  of  the  bladder  without  serious  harm ;  but 
my  belief  is  that  if  the  face-wall  of  the  bladder  be  included 
in  the  firmly  closed  jaws  the  patient  will  die.  It  cannot  be 
too  carefully  provided  against,  not  only  by  skill  in  the  opera- 
tor, but  also  in  the  construction  of  the  instrument  itself,  and 
especially  during  a  protracted  operation,  while  water  is  escap- 
ing and  the  bladder  collapsing.  With  this  object,  the  shoe  is 
here  wider  and  longer  than  is  usual,  to  repel  the  vesical  walls 
(Fig.  9). 

1  e,  Male  blade,  presenting  on  alternate  sides  triangular  notches.  The 
small  portion  of  debris  not  discharged  laterally  by  these  notches  is 
driven  through  the  slot  in  the  female  blade.    /,  Slot  in  the  female  blade. 


Fig.  9.1 


214  RAPID   LITHOTRITY. 

It  can  hardly  be  doubted  that  in  practice  dexterous  opera- 
tors secure  most  stones  and  fragments  as  they  gravitate  into 
the  female  blade  while  it  depresses  the  floor  of  the  bladder, 
perhaps  a  little  to  one  side  or  the  other,  where  the  stone 
is  felt.  A  simple  and  efficient  manoeuvre,  especially  for  a 
small  fragment,  is  that  of  opening  the  blades  of  the  litho- 
trite  widely  in  the  vertical  position,  then  slowly  turning  them 
to  one  side  and  closing  them  along  the  floor  of  the  bladder. 
If  in  attempting  this  the  instrument  be  opened  after  it  is 
turned,  the  male  blade  displaces  the  fragment  without  secur- 
ing it ;  and  it  is  of  course  understood  that  in  opening  the 
lithotrite  the  blade  in  contact  with  the  bladder,  commonly 
the  female  blade,  is  stationary.  The  inverted  lithotrite  works 
efficiently  in  a  depression,  if  the  bladder  be  kept  out  of 
harm's  way  by  a  special  device ;  but  with  the  common  litho- 
trite it  is  essential  to  turn  the  blades  up  before  crushing, 
and  move  them,  in  order  to  be  sure  they  are  free.  Indeed, 
whatever  be  the  position  of  the  lithotrite,  it  is  important  al- 
ways to  give  it  a  little  rotation  before  screwing  down,  to  see 
if  it  is  free  from  the  mucous  membrane.  This  habit  also 
keeps  the  operator  informed  whether  he  has  room,  or  needs 
more  water  in  the  bladder.  In  the  exceptional  case  of  a 
stone  behind  the  prostate,  it  may  be  necessary  to  invert  the 
lithotrite  and  seek  it.  Fragments,  however,  are  readily 
washed  from  this  region  within  reach  of  the  evacuating  tube 
by  occasionally  turning  the  orifice  and  directing  the  stream 
from  the  tube  upon  tliem. 

While,  many  years  ago,  I  had  not  infrequently  prolonged 
lithotrity  to  ten  or  fifteen  minutes,  and  longer,  it  is  only 
within  two  years  that  I  have  aimed  at  the  evacuation  of  a 
considerable  stone  during  a  single  sitting ;  and  although 
experience  will  perhaps  be  necessary  to  determine  precisely 
what  cases  are  unfavorable  to  such  an  operation,  there  can 
now  be  no  question  that  it  is  practicable  to  remove  at  once 


RAPID  LITHOTRITY.  215 

a  far  greater  quantity  of  debris  than  has  hitherto  been  con- 
sidered possible.  The  conditions  most  favorable  to  lithotrity 
are  obviously  most  favorable  to  this  modification  of  it, —  a 
stone  neither  very  large  nor  hard,  and  especially  a  large 
urethra,  promising  its  best  results.  But  if  the  preceding 
views  are  correct,  the  future  of  lithotrity  lies  in  the  direction 
of  a  fast-working  lithotrite,  which  while  it  effectually  pro- 
tects the  bladder  is  more  powerful  than  the  usual  mstru- 
ment,  and  better  proportioned  to  the  work  it  is  to  do,  —  a 
rapid  comminution  of  the  stone.  This  is  necessary  in  order 
to  secure  its  immediate  and  complete  evacuation  by  means 
of  a  large  tube  with  an  efficient  orifice.  It  will  he  no  longer 
essential  to  pulverize  the  stone,  hut  only  to  comminute  it;  and 
if  in  so  doing  the  lithotrite  can  be  kept  free  from  impaction, 
the  process  will  be  more  rapid  and  efficient. 

During  the  last  year  I  removed  by  lithotomy  two  soft  stones, 
weighing  1272  and  1230  grains,  from  two  male  adults,  aged 
forty  and  twenty-four  respectively,  who  recovered  after  various 
risks.  I  cannot  but  think  that  with  a  tolerably  sound  blad- 
der, a  urethra  of  good  size,  a  large  lithotrite,  and  a  large 
tube,  the  operation  might  have  been  performed  with  less  risk 
by  the  method  of  lithotrity  now  described. 

We  get  a  useful  view  of  the  interior  of  the  bladder  by  exam- 
ining it  in  position  through  an  opening  in  its  summit.  This 
part  of  the  organ  with  the  free  and  thin  posterior  wall  is  mainly 
concerned  in  distention.  The  floor  of  the  bladder  is  compara- 
tively firm  and  flat,  and  if  the  subject  be  in  good  condition 
adheres  to  a  thick  mass  of  cellular  tissue  in  and  near  the 
ischio-rectal  fossae  upon  which  it  rests.  This  mass  is  trav- 
ersed by  the  rectum  variously  distended  ;  and  this  canal  in 
a  thin  subject  may  be  advantageously  filled  with  air  during 
an  operation  to  facilitate  its  indentation  by  an  instrument, — 
reversing  for  the  operation  of  lithotrity  one  of  the  precepts  of 
lithotomy. 


216 


RAPID  LITHOTRITY. 


Note.  —  Figs.  10  to  14  show  plaster  casts  of  bladders  variously  dis- 
tended, and  holding  instruments  to  show  the  effect  of  a  slight  pressure 
in  indenting  the  floor  of  the  bladder  in  order  to  facilitate  the  approach  of 
fragments.  The  dotted  line  near  the  summit  of  each  represents  the  level 
of  an  air  cavity,  which  makes  it  possible  to  place  the  cast  in  the  exact 
position  it  occupied  in  a  horizontal  subject. 


Fig.  11.2 


Fig.  lla. 


1  Figs.  10  and  10  a  present  side  and  front  views  of  a  distended  bladder 
of  singular  symmetry.  The  original  suggests  in  profile  the  torso  of  a  Sile- 
nus,  the  pectoral  pouches  overhanging  the  pubes,  the  abdomen  beneath 
the  symphysis,  while  the  hollow  loins  were  cushioned  on  the  sigmoid 
flexure  which  indented  them.  The  extremity  of  a  curved  tube  is  seen 
below,  at  the  apex  of  an  inverted  tunnel,  and  just  above  it  is  a  trace  of 
the  vesical  valve.     These  figures  are  one  fifth  larger  than  the  others 

-  Figs.  11  and  11  a  show  a  less  distended  bladder,  containing  a  straight 
tube  which  indents  the  posterior  wall. 


RAPID  LITHOTRITY. 


217 


Fig.  12.1 


Fig.  12  a. 


Fig.  13.2 


lit..  13  a. 


Fig.  14  a. 


1  Figs.  12  and  12  a,  — a  bladder  with  a  curved  tube  brought  forward 
behind  the  prostate,  slightly  indenting  the  floor. 

2  Figs.  13  and  13  a,  —  a  bladder  containing  a  large  lithotrite,  which 
has  so  depressed  the  floor  that  the  posterior  wall  rises  perpendicularly. 

«  Figs.  14  and  14  a,  —  a  bladder  with  a  very  small  injection,  imprison- 
ing a  lithotrite. 


218  KAPID  LITHOTRITY. 

The  sigmoid  flexure  is  largely  concerned  in  compressing  the 
bladder  behind.  The  posterior  wall  of  this  viscus  may  be  so 
crowded  by  the  intestines  as  to  become  flat  or  even  concave. 
A  horizontal  section  of  the  bladder  is  then  transversely  oval, 
flattened  between  the  intestines  behind  and  the  piibes  in  front, 
each  of  these  indenting  it.  A  well-filled  or  tense  abdomen 
tends  so  to  sliorten  the  antero-posterior  diameter  of  the  blad- 
der, that,  while  a  large  stone  may  gravitate  backward  into  that 
part  of  the  bladder  which  is  compressed  by  the  intestines, 
carrying  the  thin  wall  with  it,  it  is  not  so  with  a  small  frag- 
ment, which  unless  the  floor  be  artificially  depressed  may  lie 
on  one  side  or  the  other  of  the  vesical  orifice  more  readily 
than  at  a  considerable  distance  behind  it.  So,  in  sounding 
with  a  curved  sound,  it  may  sometimes  be  a  little  diflicult  to 
move  the  instrument  back  and  forth  in  the  urethra,  although 
its  extremity  may  be  readily  turned  down  upon  the  floor  of 
the  bladder  on  either  side.  It  is  seen  also  (Figs.  11,13,14), 
as  a  result  of  this  conformation,  that  a  lithotrite,  or  straight 
tube,  standing  at  an  angle  of  forty-five  degrees  with  the 
recumbent  body,  abruptly  buries  its  extremity  in  the  floor  of 
the  bladder  near  the  foot  of  the  posterior  wall,  which  then 
becomes  more  upright,  and  that  it  does  not  lie  upon  the 
centre  of  an  extended  concave  surface  as  sometimes  repre- 
sented. The  deep  pit  at  the  extremity  of  the  straight  tube 
and  the  similar  depression  made  farther  forward  by  the 
curved  and  inverted  tube  (Figs.  10  and  12)  show  how  readily 
fragments  can  be  made  to  gravitate  to  the  lithotrite,  or  to 
the  tube  orifice,  provided  the  latter  be  not  plugged  by  the 
mucous  membrane.  The  curved  tube  when  inverted  rests 
on  the  adherent  floor;  but  a  straight  tube  bearing  upon  the 
free  and  thin  posterior  wall  (Fig.  11)  should  not  be  urged 
too  forcibly  against  it.  In  either  case,  the  nearer  the  instru- 
ment approaches  a  vertical  position  the  deeper  will  be  the 
indentation.     A  pit  of  this  sort  formed  in  the  elastic  floor  by 


RAPID  LITHOTRITY.  219 

an  almost  insensible  pressure  of  the  instrument  explains  the 
observation  of  Thompson,  that  when  a  fragment  is  caught  by 
the  lithotrite  many  more  are  likely  to  be  caught,  like  fish  in 
a  pool,  in  the  same  place.  A  central  indentation  of  the  floor 
also  explains  how  in  certain  cases  of  large  stone  a  lithotrite 
or  sound  may  be  passed  back  and  forth  beneath  it  without 
touching  it,  unless  the  beak  is  tilted  up.  The  stone  may 
then  seem  to  adhere  to  the  upper  wall  of  the  bladder,  and 
to  be  suspended  from  it.  During  an  operation  of  lithotomy, 
I  have  myself  been  deceived  in  this  way  up  to  the  moment 
of  introducing  the  finger  into  the  bladder.  I  am  not  aware 
that  this  common  source  of  error  in  diagnosis  has  been  be- 
fore pointed  out.     An  adherent  stone  is  rare. 

Case  I.  —  December  14,  1875.  Age,  sixty-four.  Date  of  symp- 
toms, six  3'ears.  Two  or  three  stones  measuring  from  half  an  inch 
to  more  than  three  quarters.  Three  sittings.  First  sitting:  no  frag- 
ments were  removed  through  a  tube.  Second  sitting:  interval,  seven 
days;  duration,  forty-five  minutes  under  ether;  quantity  removed, 
"a large  mass  of  fragments;"  size  of  tube,  twenty-seven.  Third  sit- 
ting: interval,  twelve  days;  quantity  removed,  "a,  few  fragments." 
Result :  the  patient  was  discharged  well  one  week  after. 

Case  IL — May  15,  1876.  Age,  sixty.  Date  of  symptoms,  twenty 
years.  Two  stones  of  one  and  one  quarter  inches  and  three  quarters 
of  an  inch  diameter  respectively.  One  sitting :  duration,  one  hour 
and  a  half  under  ether  ;  lithotrite  introduced  three  times;  quantity 
removed,  one  hundred  and  sixty-seven  grains ;  size  of  tube,  twenty- 
nine;  there  was  afterw^ard  a  slight  cystitis;  no  fragments  were 
passed;  in  two  weeks  the  patient  w^as  again  sounded,  and  no  frag- 
ments were  found.     Result:  discharged  well. 

Case  III.  —  August  6,  1876.  Age,  sixtj^-two.  Date  of  symp- 
toms, eighteen  months.  Several  stones,  none  larger  than  three 
quarters  of  an  inch.  The  patient  was  confined  to  the  house  in  great 
pain,  drawing  his  w-ater  every  half-hour  or  less.  The  prostate  was 
unusually  large.  One  sitting :  duration,  about  one  hour  and  three 
quarters  under  ether;  size  of  tube,  twenty-nine.  He  afterward 
passed  a  few  grains  of  sand  only.      Result :   no  unfavorable  symp- 


220  RAPID   LITHOTRITY. 

toms ;  almost  entire  relief  from  pain ;  later,  no  difficulty  in  retaining 
water,  but  continues  to  pass  a  catheter;  gained  ilesli  and  former 
health,  and  resumed  avocation. 

Case  IV.  —  December  14,  1876.  Age,  sixty-six.  Date  of  symp- 
toms, two  years.  Single  stone.  One  sitting:  duration,  about  an 
hour  under  ether;  quantity  removed,  one  hundred  and  eleven  grains; 
size  of  tube,  twenty-eight.  Eesult:  the  patient  did  well  for  two 
days;  then  there  was  a  chill  with  higher  temperature,  pain  in  the 
back,  and  pain  referred  to  the  left  hip;  a  gradually  failing  pulse; 
moderate  meteorism,  with  but  little  tenderness;  death  on  the  sixth 
day.     An  autopsy  was  not  permitted. 

Case  V. — January  8,  1877.  Age,  fifty-five.  Date  of  symptoms, 
one  year.  Single  stone.  "  A  severe  chill  followed  the  primary  ex- 
amination." Seven  days  after,  the  meatus  was  incised  and  enlarged 
from  twenty-eight  to  thirty-one.  One  sitting:  diameters  of  stone, 
ten  to  twenty  millimetres;  duration,  one  hour  under  ether;  size  of 
tube,  thirty-one.  Result :  no  sand  or  fragments  were  afterward 
passed;    nor  were  there  any  subsequent  symptoms. 

Case  VI.  —  April  21,  1877.  Age,  forty-three.  Single  stone 
with  nucleus  of  dead  bone.  Five  vears  ago  the  pelvis  of  this 
patient  was  crushed.  Sinuses  discharging  dead  bone  opened  on 
both  hips.  Six  months  after  the  injury  symptoms  of  stone  ex- 
isted. One  sitting:  duration,  one  hour  and  a  half  under  ether; 
meatus  incised;  size  of  tube,  thirty;  quantity  removed,  sixty-six 
grains,  and  also  three  small  pieces  of  bone,  doubtless  nuclei,  one 
of  which  was  incrusted;  an  indurated  spot  was  detected  by  the 
tube  where  the  bladder  seemed  to  adhere  to  the  pelvis.  Four 
days  after,  under  ether,  the  lithotrite  brought  away  with  difficulty 
through  the  urethra  a  square  scale  of  bone  too  elastic  to  be  bro- 
ken, measuring  five  eighths  of  an  inch  by  seven  sixteenths,  but 
no  sand  or  fragments.  Eesult:  there  were  no  unpleasant  symp- 
toms at  any  time ;  and  after  another  careful  examination  for  bone 
the  patient  was  discharged  well. 

Case  VII.  —  (Dr.  T.  B.  Curtis's  case.)  March  6,  1877.  Age, 
fifty-four.  Date  of  symptoms,  two  years.  Single  stone.  One  sit- 
ting: diameter  of  stone,  one  inch  and  a  quarter;  duration,  one  hour 
and  twenty-five  minutes  under  ether;  lithotrite  introduced  three 
times;    size  of  tube,  thirty-one;  quantity  removed,  when  dry,  two 


KAPID  LITHOTRITY.  221 

hundred  and  fifty-seven  grains;  the  six  largest  fragments  weighed 
together  twenty -four  grains;  the  strained  urine  yielded  during  the 
next  week  two  and  one  half  grains.  Result :  rapid  recovery,  with 
no  subsequent  symptoms. 

Case  VIII.—  (Dr.  C.  B.  Porter's  case.)  August  19,  1877.  Age, 
sixty-one.  A  large,  flabby  man,  with  a  feeble  pulse.  Date  of  symp- 
toms, twenty-six  years.  Two  stones :  one  so  large  that  it  was 
barely  possible  to  lock  the  lithotrite.  Passes  water  every  fifteen 
or  twenty  minutes.  Three  sittings.  First  sitting :  duration,  one 
hour  and  a  half  under  ether;  size  of  tube,  twenty-eight;  quan- 
tity removed,  two  hundred  and  twenty-eight  grains;  passed  after- 
ward one  hundred  and  eight  grains.  Second  sitting:  interval,  four 
days;  duration,  three  hours  under  ether;  size  of  tube,  thirty;  quan- 
tity removed,  seven  hundred  and  forty-four  grains;  passed  afterward 
sixteen  grains;  no  after  symptoms  of  importance.  Third  sitting: 
interval,  five  days;  duration,  three  and  three  quarter  hours  under 
ether;  size  of  tube,  thirty-one;  quantity  removed,  seven  hundred 
and  six  grains;  no  pain  or  discomfort  afterward;  total  number  of 
grains  after  drying,  one  thousand  eight  hundred  and  two.  Re- 
sult :  discharged  well  two  weeks  from  the  date  of  the  first  opera- 
tion; after  a  few  weeks  the  patient  could  retain  his  water  from 
three  to  four  hours. 

The  details  of  the  earlier  of  these  operations  are  expressed 
with  less  exactness  than  I  might  now  desire,  but  were  dictated 
by  myself  at  the  time,  and  are  within  the  fact  as  to  the  dura- 
tion of  each  operation  and  the  size  of  the  stones.  The  cases, 
all  of  soft  stones, — that  is,  not  oxalate  of  lime, — are  the  only 
ones  by  which  the  method  that  is  the  subject  of  this  paper 
has  been  tested.  As  statistics,  they  are  not  so  numerous  as 
to  have  importance.  But  they  abundantly  illustrate  what  this 
operation  is  able  to  accomplish  in  removing  at  once  a  large 
quantity  of  stone  by  the  urethra.  The  fatal  case  without  an 
autopsy,  the  absence  of  which  is  greatly  to  be  regretted,  must 
pass  for  what  it  is  worth.  The  other  cases  demonstrate  a  tol- 
erance by  the  bladder  of  protracted  manipulation  which  has 
not  hitherto  been  recognized. 


222  RAPID   LITHOTRITY. 

Since  the  above  was  published,  six  cases  have  been  success- 
fully treated  by  the  new  method,  —  making  fourteen  cases  in 
all,  with  one  death,  which  is  about  the  proportion  of  fatality 
in  Sir  Henry  Thompson's  list  of  four  hundred  and  twenty-two 
cases,  with  sittings  of  three  minutes'  duration.  Among  the 
later  cases,  two  of  the  three  which  occurred  in  my  own  prac- 
tice offered  exceptional  interest.  In  the  first  case,  a  calculus 
lodged  deep  in  the  urethra  was  removed.  A  contracted  ure- 
thra was  then  enlarged  by  divulsion  with  Voillemier's  in- 
strument, a  No.  31  tube  was  introduced,  and  a  considerable 
quantity  of  thick  mucus  was  immediately  evacuated.  This 
was  found  to  contain  twenty-five  grains  of  phosphatic  frag- 
ments, the  whole  mass  being  so  voluminous  that  it  could 
not  probably  have  been  otherwise  as  well  withdrawn.  In  the 
second  case,  the  extremity  and  wings  of  a  red  rubber  cathe- 
ter had  been  lost  in  the  bladder.  After  the  stone  of  which 
these  formed  the  nucleus  was  broken,  the  fragments  of  cathe- 
ter came  through  the  tube  at  once.  The  following  are  the 
cases :  — 

Case  IX. — Patient  aged  fifty.  Twenty-five  grains  of  phosphatic 
deposit  evacuated;  time,  four  minutes.  1861,  the  urethra  was 
opened  to  remove  impacted  gravel.  1863,  he  was  cut  for  stone,  and 
has  occasionally  passed  gravel  since.  1876,  he  was  o^jerated  on  for 
stricture,  and  has  passed  a  No.  12  sound  until  within  two  weeks ; 
one  week  ago  he  voided  a  stone  ''as  large  as  the  end  of  his  little 
finger."  Now  he  has  frequent  micturition,  and  an  impacted  stone 
is  felt  in  the  urethra  just  behind  the  scrotum.  This  stone  was  bro- 
ken, and  ten  grains  were  removed  with  long  forceps.  The  rigid 
and  cicatricial  urethra  was  next  divulsed.  The  bladder  was  evacu- 
ated through  a  twenty-nine  tube,  yielding  about  one  and  a  half 
ounces  of  mucus  and  gravel,  the  latter  weighing  when  dry  twenty- 
five  grains.  The  walls  of  the  urethra  were  now  scraped  with  the 
female  blade  of  a  small  urethral  lithotrite,  to  remove  an  abundant 
and  closely  adherent  calculous  deposit.  During  the  succeeding  five 
days  the  temperature  and  pulse  remained  nearly  normal,  frequent 
micturition  being  somewhat  relieved  by  opiates.     For  a  dull  pain 


RAPID  LITHOTRITY.  223 

in  tlie  urethra  after  urinating,  water  was  injected  to  wash  the  pass- 
age after  each  micturition,  —  an  expedient  I  have  long  employed 
in  the  treatment  of  gonorrhcea,  and  also,  in  imitation  of  the  usual 
practice  after  strong  applications  to  the  eye,  to  terminate  abruptly 
the  action  of  strong  gonorrhoeal  injections  in  the  urethra.  The 
patient  did  well.  At  the  end  of  three  weeks,  a  single  phosphatic 
concretion  as  large  as  a  small  pea  was  discovered  and  removed 
through  a  twenty-six  tube. 

Case  X.  —  Patient's  age  fifty.  Eighty-two  grains  of  stone  with 
a  rubber  catheter  nucleus  were  evacuated;  whole  time,  twenty-jEive 
minutes.  Eighteen  weeks  ago,  daring  the  treatment  of  a  traumatic 
laceration  of  the  urethra,  a  winged  rubber  catheter  was  kept  in  the 
bladder.  A  portion  of  this  was  broken  off  and  remained  there, 
causing  in  a  few  days  frequent  micturition  and  cloudy  urine.  Five 
weeks  ago  a  stone  was  discovered.  Now  there  is  frequent  micturi- 
tion, and  abrupt  stoppage  followed  by  pain  in  the  glans  penis.  The 
bladder  was  filled  and  emptied, —  the  fluid  measuring  half  a  pint, 
which  quantity  was  again  injected.  By  the  lithotrite  the  stone 
measured  nearly  an  inch  and  a  quarter,  being  doubtless  caught 
lengthwise.  A  certain  elasticity  of  the  closed  blades  led  to  their 
withdrawal  with  a  small  fragment  of  brittle  rubber.  This  with- 
drawal was  twice  repeated  with  bits  of  rubber,  including  the  two 
wings  and  also  twenty-seven  grains  of  stone.  The  whole  operation 
had  now  lasted  nine  minutes.  A  straight  evacuating  tube,  No.  31, 
was  next  introduced,  and  the  bladder  pumped  during  four  min- 
utes, after  which  it  yielded  no  more  foreign  material.  Almost  all 
the  stone  thus  evacuated  (fifty-five  grains),  together  with  three 
bits  of  rubber  catheter  measuring  respectively  three  fourths,  seven 
eighths,  and  one  fourth  of  an  inch  in  length,  and  No.  23  Char- 
riere  in  diameter,  came  through  the  tube  within  the  first  min- 
ute. The  lithotrite  was  now  again  introduced,  but  nothing  more 
discovered;  after  which  the  bladder  was  again  washed  out.  The 
entire  operation  lasted  twenty-five  minutes,  much  of  which  was 
occupied  in  determining  the  fact  that  the  bladder  had  been  evac- 
uated. The  next  night  the  patient  had  no  pain,  and  micturated 
but  twice  instead  of  six  times  as  habitually  before.  Two  days 
after,  the  temperature  suddenly  rose  to  102°  Fahrenheit,  but  as 
quickly  subsided  without  other  sign  or  symptom,  the  patient  be- 
ing entirely  relieved. 


224  KAPID  LITHOTRITY. 

Case  XI.  — Patient's  age,  sixty -two.  Date  of  symptoms,  three 
3^ears.  Two  stones,  lithic  ;  largest  diameter,  thirty  millimetres. 
One  sitting:  duration,  one  hour  and  twenty  minutes;  size  of 
tubes,  twenty-nine  and  thirty;  quantity  removed,  three  hundred 
and  nineteen  grains;  urethra  somewhat  contracted  in  front  of 
scrotum.  In  evacuating  these  stones  the  time  was  found  to  have 
been  occupied  as  follows:  crushing,  twenty-nine  minutes;  evacu- 
ating, twenty-four  minutes ;  the  rest  of  the  time  being  consumed 
in  passing  and  withdrawing  the  instruments,  renewing  the  water, 
etc.  As  usual,  most  of  the  fragments  passed  the  tube  early  in  the 
operation,  and  readily,  much  of  the  time  occupied  by  the  evacua- 
ation  being  consumed  in  making  sure  that  no  fragments  were  left 
behind.  Micturition  before  the  operation  once  every  hour  and  a 
half;  after  the  operation  about  once  an  hour,  and  obstructed  by 
purulent  mucus.  The  j)atient  had  a  large  though  yielding  pros- 
tate. The  water  was  drawn  during  eight  days;  at  the  end  of 
which  he  was  generally  able  to  relieve  himself,  the  purulent  mu- 
cus having  diminished  in  quantity.  The  testicles  were  some- 
what swollen.  Though  still  under  treatment,  the  patient  is  fairly 
convalescent. 

A  discussion  of  the  relative  values  of  lithotrity  and  lithot- 
omy, at  a  recent  meeting  of  the  Royal  Medical  and  Chirnrgi- 
cal  Society ,1  has  interest  in  this  connection,  because  it  exposes 
the  current  English  views  upon  this  subject,  while  it  gives 
prominence,  by  contrast,  to  the  advantages  of  the  new  method 
of  lithotrity  over  the  old  one.  It  is  evident  that  the  large 
tubes  offer  a  ready  means  for  preventing  the  recurrence  of 
stone  by  either  nuclei  or  fragments,  which  is  "  by  no  means 
uncommon "  after  lithotrity,  as  Mr.  Cadge  remarked,  and 
"  one  of  its  serious  defects ; "  also,  for  removing  the  phos- 
phatic  deposits  which,  in  the  words  of  Sir  Henry  Thompson 
on  that  occasion,  are  "  not  unfrequently  left  after  lithotrity," 
"  being  due  to  the  injury  done  to  the  mucous  membrane  by 
sharp  fragments  of  stone,  and  by  continued  instrumentation." 
Sir  Henry  looked  iipon  them  as  "  unavoidable,  and  as  a  price 

1  March  12,  1878.     See  "  The  Lancet,"  March  16,  1878. 


RAPID  LITHOTRITY.  225 

paid  for  the  greater  security  to  life  which  lithotrity  affords." 
Again,  Sir  Jaraes  Paget  said  "  he  must  confess  to  a  general 
feeling  in  favor  of  lithotomy  over  lithotrity,"  unless  "the 
calculus  can  be  got  rid  of  in  two  or  three  sittings."  Sir 
Henry  Thompson  on  this  subject  said,  "  Three,  or  at  most 
four  sittings,  at  which  point  he  should  distinctly  prefer  to 
cut." 

The  obvious  question  then  is  whether  in  adult  patients, 
when  the  stone  requires  more  than  three  or  four  sittings  of 
a  few  minutes  each,  by  the  old  method,  it  is  safer  to  cut,  or 
to  employ  the  new  and  rapid  lithotrity,  with  evacuation.  The 
latter  must  be  preferred  to  lithotomy,  in  cases  now  rejected 
by  the  lithotritist,  unless  it  can  be  shown  that  its  mortality 
amounts  to  one  in  three,  —  this  being  the  death-rate  of  lithot- 
omy in  such  cases,  as  stated  during  the  discussion.  So  great 
a  mortality  from  the  new  operation  is  improbable. 

There  can  be  no  doubt  of  the  importance  of  the  complete 
evacuation  of  final  fragments,  renal  nuclei,  phosphatic  masses, 
and  foreign  bodies. 

In  the  matter  of  crushing,  stress  was  justly  laid  upon  the 
difficulty  of  withdrawing  the  impacted  lithotrite  from  the 
bladder,  —  both  Sir  Henry  Thompson  and  Mr.  Coulson  speak- 
ing of  fragments  actually  "  preventing  the  withdrawal  of  the 
instrument,"  and  "  requiring  in  one  case  incision  in  the  peri- 
ngeum."  This  difficulty  is  obviated  by  the  new  notched  litho- 
trite, which  effectually  clears  itself.  It  also  permits  more 
expeditious  work.  The  larger  size,  as  made  by  Collin,  is 
much  more  powerful  than  the  usual  lithotrite,  while  it  can 
readily  be  introduced  into  a  bladder  that  will  admit  a  No.  27 
tube. 

As  the  female  urethra  is  so  easily  dilated,  the  new  lithot- 
rity will  doubtless  prove  to  be  tlie  easiest  way  to  dispose  of 
calculi  in  the  female,  the  tubes  being  made  shorter  and  larger 
than  for  the  male  urethra. 

15 


226  RAPID  LITHOTRITY. 

I  may  again  say,  in  conclusion,  that  since  its  first  an- 
nouncement this  method  of  evacuation  has  been,  by  repeated 
experiment,  so  modified  and  reduced  to  a  system,  as  to  have 
become  much  more  rapid  and  efficient.  The  time  then  con- 
sumed by  the  operation,  although  it  showed  a  surprising  to- 
lerance of  the  bladder,  is  no  criterion  of  the  time  now 
required  for  accomplishing  the  same  result.  The  improve- 
ments relate  chiefly  to  the  systematic  dispersion  or  collec- 
tion of  fragments  in  the  bladder,  to  the  position  of  the  tube, 
and  to  the  recognition  and  immediate  removal  of  obstruc- 
tion. A  considerable  part  of  the  time  is  still  consumed 
in  ascertaining  whether  the  stone  is  wholly  evacuated,  —  a 
large  part  of  it  being  usually  removed  at  the  beginning  of 
the  operation. 

The  following  are  the  chief  points  connected  with  the 
modification  in  lithotrity  which  I  have  described :  — 

1.  The  calculus,  although  not  necessarily  pulverized,  is 
crushed  as  rapidly  and  completely  as  is  practicable.  The 
dust  and  fragments  are  immediately  evacuated,  and  a  serious 
source  of  irritation  is  thus  removed. 

2.  This  can  be  generally  effected  in  a  single  operation. 

3.  The  operation  (performed  of  course  under  ether)  may  be, 
if  necessary,  of  one  or  two  hours'  duration,  or  even  longer. 

4.  The  method  applies  to  larger  stones  than  have  been 
hitherto  considered  to  lie  within  the  province  of  the  lithotritist. 
It  also  applies  to  small  stones,  nuclei,  phosphatic  deposits, 
and  foreign  substances. 

5.  Evacuation  is  best  accomplished  by  a  large  tube, 
preferably  straight,  —  with  a  distal  orifice,  the  extremity 
of  which  is  shaped  to  facilitate  its  introduction  and  (during 
suction)  to  repel  the  bladder  wall,  —  and  by  an  elastic  ex- 
hausting bulb  which  acts  partly  as  a  siphon.  Below  the 
latter  is  a  glass  receptacle  for  debris. 


RAPID  LITHOTRITY.  227 

6.  The  best  size  for  the  tube  is  the  largest  the  urethra  will 
admit. 

7.  Such  a  tube  is  usually  introduced  with  facility,  if  passed 
vertically  as  far  as  it  will  go  toward  the  anus  before  chang- 
ing its  direction,  and  afterward  directed  almost  horizontally, 
and  passed  by  rotation  through  the  triangular  ligament.  The 
first  part  of  this  rule  applies  also  to  the  introduction  of  a 
lithotrite,  and  even  a  curved  catheter.  A  free  injection  of  oil 
is  important. 

8.  A  small  meatus  should  be  enlarged,  or  a  stricture  di- 
vulsed,  to  allow  the  passage  of  a  large  tube. 

9.  If  the  bladder  be  not  small,  a  large  and  powerful  litho- 
trite is  always  better  than  a  small  one. 

10.  That  this  may  have  room  for  action,  the  escaping 
water  should  be  replaced  occasionally  through  a  tube  inserted 
a  few  inches  into  the  urethra  by  the  side  of  the  lithotrite. 
But  the  bladder  should  not  be  over-distended. 

11.  To  save  time,  and  also  to  prevent  undue  dilation  of 
the  vesical  neck,  a  non-impacting  lithotrite  is  desirable.  The 
jaws  of  a  non-fenestrated  instrument  will  not  impact  if  the 
male  blade  is  furnished  with  alternate  triangular  notches  by 
which  the  debris  is  discharged  laterally,  and  also  with  a 
long  thin  spur  at  the  heel  fitted  to  a  corresponding  slot  in 
the  female  blade,  —  provided  the  floor  of  the  female  blade, 
especially  at  the  heel,  be  made  nearly  on  a  level  with  its 
rim.  To  repel  the  bladder,  tfce  female  blade  should  be  longer 
and  a  little  wider  than  is  usual.  It  should  have  also  low 
sides  easily  accessible  to  fragments,  —  relying  for  strength 
less  upon  these  than  upon  a  central  ridge  below  the  heel.  In 
the  male  blade  of  such  a  lithotrite,  the  apices  of  the  triangles 
should  be  a  little  blunted.  Lastly,  a  non-fenestrated  female 
blade  protects  the  floor  of  the  bladder  during  a  long  sitting. 
A  fenestrated  instrument  directs  sharp  splinters  against 
it.     The  latter  also  delays  the  process  of  disintegration  by 


228  RAPID  LITHOTRITY. 

delivering  through   its    opening   the   same  fragments   many 
times. 

12.  In  locking  and  unlocking  a  lithotrite  repeatedly  in  a 
long  operation,  it  takes  less  time  and  is  easier  to  turn  the  right 
wrist,  as  in  my  instrument,  than  to  displace  the  thumb  of 
either  hand  in  search  of  a  button  or  a  lever,  as  in  previous 
instruments. 

The  efficiency  of  evacuation  has  recently  been  further  illus- 
trated by  the  removal  through  the  urethra,  under  ether,  with- 
out crushing,  of  thirty-five  small  calculi,  daring  a  single 
sitting  of  half  an  hour,  in  which  the  bladder  was  completely 
emptied.  The  patient  was  sixty-five  years  of  age,  the  prostate 
large.  The  stones  were  lithic,  nearly  spherical,  and  almost 
destitute  of  facets.  The  two  largest  had  a  diameter  =  34  of 
Charriere.  Of  these  stones  thirteen  were  drawn  through  a 
tube  of  the  calibre  31  Charriere.  Twenty-two  were  arrested 
in  the  tube,  —  the  smaller  being  detained  by  other  larger 
stones  simultaneously  engaged  in  its  extremity,  into  which 
they  closely  fitted.  Thus  obstructed,  the  tube  was  withdrawn 
ten  times,  always  with  one  or  more  calculi.  The  stones, 
when  dry,  weighed  two  hundred  and  forty  grains.  I  used  in 
this  instance  a  tube  having  a  long  oval  orifice  with  a  thick 
edge,  passing  the  latter  through  the  meatus,  and  especially 
the  prostatic  portion  of  the  canal,  with  facility,  by  rotating 
the  tube. 

Such  an  operation  can  hardly  be  called  lithotrity.  I  have 
therefore  proposed  for  the  new  method  the  name  Litholap'- 
axy,  —  \ldo<i,  and  XaTra^t?  (^evacuations . 


RAPID  LITHOTRITY.  229 


RAPID   LITHOTRITY,  WITH   EVACUATION.i 

To  THE  Editor  : 

An  article  by  Dr.  Kejes  in  your  last  issue  (May  18)  gives 
me  occasion  to  refer  to  one  or  two  misapprehensions  which 
pervade  his  allusions  to  "Modern  Lithotrity,"  as  he  terms 
the  new  operation  for  stone. 

In  this  article,  which  is  devoted  mainly  to  a  description  of 
the  jaws  of  a  lithotrite,  the  writer  states  that  my  lithotrite 
"  must  sometimes  clog,"  because  "  it  is  made  on  the  principle 
of  Reliquet's."  He  is  mistaken.  In  the  first  place,  Reliquet's 
instrument  is  fenestrated ;  mine  is  solid.  In  the  second  place, 
as  an  ascertained  fact,  my  lithotrite  does  not  impact.  The 
male  blade  is  furnished  with  lateral  notches  forming  inclined 
planes  by  which  the  detritus  is  extruded  right  and  left,  except 
where  a  small  portion  at  the  heel  is  driven  through  a  slot 
by  an  effective  spur.  Reliquet's  non-impacting  lithotrite  is 
identical  with  the  obsolete  fenestrated  brisepierre,  with  teeth 
in  the  opening  below  to  insure  pulverization.  Dr.  Keyes  pro- 
poses to  remove  these  added  teeth,  and  return  to  the  brise- 
jyierre  a  inors  fenetre  (^jjorte  a  faux)  of  Charriere.^  In  fact, 
he  goes  back  to  the  flattened  jaws  of  the  "  slightly  indented 
and  fenestrated  or  open  female  blade"  figured  by  Costello,^ 
with  a  male  blade  as  small  as  in  the  common  lithotrite,  to 
avoid  pinching  the  mucous  membrane,*  —  in  short,  to  a  com- 
mon lithotrite  with  the  floor  removed. 

1  Xew  York  Medical  Record,  June  8,  1878. 

2  Nouveau  Dictionnaire  de  Medecine  et  de  Chirurgie,  torn.  xx.  p.  667. 
Paris,  1875. 

8  Cyclopfedia  of  Practical  Surgery,  vol.  iii.  pp.  21,  50.     London,  1861. 

■*  The  mucous  membrane  would  be  more  secure  if  care  were  taken 

always  to  blunt,  or  round  a  little,  the  edge  of  the  sole  of  the  male  blade. 


230  RAPID  LITHOTRITY. 

I  am  gratified  to  find  that  the  writer  of  the  article  indorses 
my  statement  (which  is  an  important  corollary  of  the  new 
system)  that  "m  future  it  ivill  he  no  longer  essential  to  pul- 
verize the  fragments,  hut  only  to  comminute  themP  This  may 
be  accomplished  by  either  a  fenestrated  or  a  solid  instrument. 
Any  fenestrated  lithotrite  that  sufficiently  reduces  the  size  of 
fragments  driven  through  it,  enables  them  to  pass  the  evac- 
uating tubes,  the  use  of  which  characterizes  the  new  method. 
But  although  instruments  of  this  class  will  doubtless  do  well 
enough  with  small  stones,  as  does  indeed  a  common  lithotrite, 
my  objections  to  a  fenestrated  instrument,  of  which  I  consid- 
ered and  rejected  several  (including  that  proposed  in  your 
journal),  are  these:  — 

1.  Sharp  fragments,  while  firmly  engaged  in  the  opening, 
or  driven  through  it,  are  likely  to  injure  the  floor  of  the  blad- 
der. During  a  long  operation,  such  as  I  propose,  it  is  hardly 
possible  to  prevent  the  frequent  contact  of  the  floor  of  the 
bladder  with  the  extremity  of  the  instrument;  in  which  case 
the  latter  does  not  present  to  the  mucous  membrane  a 
rounded  and  polished  surface,  but  irritates  it  with  protruding 
splinters  of  calculus,  continually  coming  in  contact  with  the 
same  limited  region  of  the  floor, 

2.  The  sides  separately  are  not  as  strong  as  when  united 
by  a  floor  of  metal,  and  if  they  are  made  low  enough  to  be 
readily  accessible  to  fragments  (which  is  important)  are  con- 
sequently liable  to  break,  especially  should  the  strain  come 
on  one  alone.  The  strength  of  a  fenestrated  blade  lies  in  the 
height  of  its  sides,  and  is  but  partially  compensated  by  their 
breadth,  unless  the  latter  is  extreme.  Moreover,  the  male 
blade  must  be  disadvantageously  narrow.  When  it  is  wide, 
the  corresponding  opening  not  only  impairs  the  strength,  but 
delivers  large  fragments. 

3.  Now,  although  fragments,  if  small  enough,  pass  the  tube 
readily,  dust  and  small  debris  pass  more  readily,  and  first. 


RAPID  LITHOTRITY.  231 

Therefore  when  a  fragment  has  been  fortunately  seized,  the 
operator  loses  an  opportunity  if  he  fails  to  crush  it,  —  as 
happens  when  he  drives  it  through  a  fenestrated  blade  to  be 
again  seized.  Although  by  the  new  method  pulverization 
is  no  longer  essential  as  before,  our  aim  is  still  to  accomplish 
a  maximum  disintegration  at  each  closure  of  the  jaws ;  and 
this  is  better  done  with  a  solid  upper  and  lower  jaw  than 
when  either  of  them  is  fenestrated.  A  non-impacting  instru- 
ment is  very  desirable,  but  not  at  the  sacrifice  of  efficient  and 
rapid  crushing,  or  with  danger  to  the  mucous  membrane. 

I  may  add  that,  to  prevent  impaction,  when  the  blades  are 
closed  it  is  quite  unnecessary  that  the  male  blade  should  pro- 
ject below  the  female  blade,  —  an  arrangement  Dr.  Keyes  has 
devised  and  emphasized  for  this  purpose,  and  a  description  of 
which,  indeed,  occupies  a  considerable  portion  of  his  paper. 
It  is  sufficient  that  the  blades  of  a  fenestrated  instrument 
occupy  the  same  level  at  the  outlet. 

Again,  the  heel  of  the  instrument  figured  in  your  journal 
has  the  form  of  the  segment  of  a  circle.  Such  curved  blades 
admit  fragments,  and  crush  them  at  great  disadvantage. 

Blades  should  be  as  straight,  set  at  as  nearly  a  right  angle 
with  the  shaft,  and  as  little  rounded  at  the  heel  as  is  compati- 
ble with  their  introduction. 

In  my  non-fenestrated  lithotrite  the  blades  are  nearly 
straight,  and  the  triangular  notches  deliver  on  alternate 
sides.  This  lateral  action  not  only  clears  the  jaws,  but 
makes  their  hold  very  tenacious.  It  also  secures  to  the 
blades  the  incidental  advantage  of  grinding  while  they 
crush. 

Your  contributor  finds  my  instrument  too  large  (or,  as  he 
says,  "clumsy").  It  is  made  large  with  a  distinct  object; 
namely,  to  break  larger  and  harder  stones  than  have  been 
hitherto  considered  within  the  province  of  the  lithotrite.  It 
comminutes,  with  safety  to  the  bladder  and  without  impac- 


232  RAPID  LITHOTRITY. 

tion,  as  no  lithotrite  hitherto  devised  has  done.  The  new 
method  of  treatment  is  grounded  in  the  fact  that  the  normal 
urethra  admits  larger  instruments,  and  is  an  easier  road  to 
the  bladder,  than  the  lithotritist  has  hitherto  recognized.  The 
operator  soon  becomes  not  only  accustomed  to  the  use  of  a 
large  lithotrite,  but  reluctantly  foregoes  the  power  it  gives  him, 
even  when  the  stone  is  small,  Collin  has,  however,  made  a 
second  size. 

While  the  power  possessed  by  this  lithotrite  and  the  fact 
that  it  does  not  impact  are  its  more  important  features,  and 
especially  adapt  it  to  the  requirements  of  the  method  now 
proposed,  almost  as  useful  is  the  change  in  its  lock.  I  believe 
that  this  will  ultimately  be  adopted  by  those  not  already 
educated  to  the  old  system,  because  it  is  based  upon  the 
readiest  movements  of  the  hand  and  wrist. 

But  a  modification  of  the  jaws  and  lock  of  the  lithotrite  is 
an  inconsiderable  feature  of  the  proposed  new  method.  Rapid 
work  is  indeed  thereby  facilitated  ;  and  an  empty  instrument 
can  safely  be  withdrawn  as  often  as  the  operator  pleases,  to 
relieve  the  bladder  of  what  will  come  through  the  tubes,  and 
so  clear  the  way  for  more  rapid  crushing. 

A  far  more  important  point  to  the  lithotritist  is  the  com- 
parative harmlessness  of  long  sittings,  which  I  think  was  un- 
suspected until  the  publication  of  my  paper.  In  the  first 
trials,  what  was  wanted  was  not  so  much  an  improvement  of 
tlie  existing  crushing  apparatus,  as  an  efficient  means  of 
evacuation,  capable  of  removing  all  the  debris  at  one  sitting. 
For  this  purpose,  the  large  tubes  criticised  in  your  journal  are 
absolutely  indispensable.  Their  use  is  precisely  what  makes 
the  new  operation  practicable,  and  together  with  their  manip- 
ulation is  perhaps  its  chief  innovation.  The  set  of  tubes 
described  in  my  paper  ranges  from  27  to  31  Charriere ;  but 
they  can  be  procured  of  any  smaller  size,  and  should  of  course 
be  adapted  to  the  previously  ascertained  calibre  of  the  urethra. 


RAPID  LITHOTRITY.  233 

It  will,  however,  be  found  that  the  efficiency  of  the  tubes 
diminishes  very  rapidly  with  their  size,  and  that  a  canal  nar- 
rowed by  stricture,  or  by  a  small  meatus,  will  require  to  be 
enlarged  so  that  the  introduction  of  a  lai-ge  tube  may  be  made 
possible.  In  such  a  case  as  that  reported,  where  the  urethra 
admitted  only  a  No.  20  instrument  (French),  and  in  which 
the  operator  of  course  found  my  largest  tubes  too  large,  I 
should  prefer  to  increase  the  size  of  the  passage  rather  than 
attempt  to  extract  the  fragments  of  a  calculus  through  the 
small  calibres  formerly  in  use,  even  though  the  tube  were 
otherwise  modified  as  I  have  recommended.  With  a  normal 
urethra  I  do  not  believe  that  the  tubes  supplied  by  Tiemann 
will  be  found  any  too  large. 

The  change  proposed  in  the  new  procedure,  and  the  conse- 
quent advantages,  will  appear  in  a  clearer  light  if  we  con- 
sider the  limitations  of  the  usual  dilatory  method  explicitly 
acknowledged,  quite  recently,  by  both  Sir  Henry  Thompson 
and  Sir  James  Paget.  These  distinguished  authorities  gave 
their  opinion  that  lithotrity  should  be  restricted  to  stones  re- 
quiring only  two  or  three  or  at  most  four  sittings  of  two  or 
three  minutes  each.  For  larger  stones,  in  their  judgment, 
lithotomy  does  better,  though  resulting,  in  adults,  in  a  mor- 
tality of  one  in  three.  It  should  be  added  that  when  lithot- 
rity was  thus  pronounced  unsuccessful  in  such  cases,  all 
attempts  at  the  immediate  evacuation  of  debris  had  resulted 
in  practical  failure. 

The  new  method  not  only  crushes  calculi  exceeding  in  size 
the  limits  hitherto  affixed  to  crushing  alone,  but  at  the  same 
sitting  evacuates  by  the  urethra  the  fragments  and  debris. 
This  is  done  under  ether,  in  a  sitting  of  one  or  two  hours' 
duration,  or  even  longer.  So  far,  its  results  have  been  better 
than  could  have  been  anticipated,  —  being  sixteen  or  seven- 
teen cases  of  complete  evacuation  with  but  one  death,  against 
one  in  thirteen  by  the  usual  method.     Several  of  these  pa- 


234  KAPID  LITHOTRITY. 

tients  would  have  been,  by  accepted  rules,  subjected  to  lithot- 
omy, and  consequently  to  a  risk  equal  to  one  death  in  three 
cases.  I  cannot  but  think  that  with  due  care  in  its  applica- 
tion the  method  now  proposed  will  be  found  to  yield  results 
at  least  as  favorable  as  those  before  obtained. 

Henry  J.  Bigelow. 

Boston,  May  25,  1878. 


LITHOLAPAXY.  235- 


LITHOLAPAXY.i 

The  object  of  this  operation  is  to  remove  at  once,  by  the 
urethra,  the  debris  created  by  the  lithotrite.  It  is  based  on 
the  belief  of  a  tolerance  by  the  bladder  of  protracted  manipu- 
lation, which  has  not  been  hitherto  recognized.  It  is  also 
based  on  a  theory  that  a  brief  manipulation,  in  the  bladder, 
of  polished  and  blunted  instruments  is  less  irritating  to  that 
organ  than  is  the  protracted  presence  of  fragments,  especially 
in  view  of  the  fact  that  the  bladder  hugs  the  latter  more  or 
less  sharply  at  each  micturition.  When  lithotrity  is  properly 
done,  the  process  of  crushing  is  easy  and  safe.  The  real 
question  relates  to  the  subsequent  disposal  of  the  fragments. 
If  the  purpose  of  the  surgeon  is  to  get  rid  of  them,  and  if 
their  evacuation  has  hitherto  been,  for  the  want  of  proper 
appliances,  slow  and  injurious  to  the  bladder,  it  is  fair  to  con- 
sider whether  this  object  cannot  be  attained  with  the  aid  of 
an  instrument  devised  to  evacuate  the  bladder  more  quickly 
through  the  urethra,  while  its  walls  are  held  apart  at  their 
full  normal  dimensions,  —  such,  for  example,  as  this  canal 
attains  when  the  meatus  is  compressed  during  the  passage 
of  urine. 

It  is  quite  safe  to  leave  this  question  to  be  settled  by  such 
further  experiments  as  shall  be  deemed  wholl}^  satisfactory. 
In  the  mean  time,  in  order  that  the  operation  of  evacuation 
may  be  accomplished  in  the  readiest  and  safest  way,  it  may 
be  well  to  offer  a  few  explanatory  suggestions  in  respect 
to  it. 

One  difficulty  at  the  outset  may  be  illustrated  by  a  simple 
experiment.     If  a  small  catheter,  surmounted  by  a  funnel,  be 

1  The  Lancet,  Nov.  2,  1878. 


236  LITHOLAPAXY. 

tied  in  an  ox's  bladder  and  held  vertically,  water  introduced 
by  the  funnel  will  distend  the  bladder  very  forcibly.  Simi- 
larly, the  hydrostatic  pressure  of  a  column  of  water  but  a  few 
inches  higher  than  the  pubes  will  distend  the  human  bladder 
beyond  its  safe  capacity.  So  that  it  may  be  assumed  that 
any  catheter  surmounted  by  a  bulb  is  more  liable  to  injure 
the  bladder  by  over-distending  it  than  when  the  bulb  is 
lowered  to  the  level  of  the  bladder  or  below  it.  The  weight 
of  a  full  bulb  in  the  former  position  also  prevents  accurate 
manipulation  of  the  catheter.  It  is  more  easily  handled  in  a 
stand. 

The  instrument  now  employed  is  a  siphon,  at  one  of  whose 
extremities  is  a  large  metal  tube  that  takes  advantage  of  the 
full  normal  capacity  of  the  urethra,  while  the  other  termi- 
nates in  an  elastic  bulb  and  glass  receptacle.  The  tube 
extremity  is  shaped  to  facilitate  its  introduction,  and  also 
so  that  its  orifice  may  be  placed,  if  necessary,  at  the  lowest 
point  in  the  bladder,  at  the  apex  of  an  inverted  funnel,  among 
the  fragments,  without  being  occluded  by  the  usual  valve-like 
action  of  the  bladder-wall.  A  straight  tube  has  advantages 
over  a  curved  one :  the  surgeon  can  more  readily  direct  it 
and  regulate  its  pressure ;  it  is  less  liable  to  obstruction,  and 
better  cleared  by  a  rod.  Again,  a  straight  instrument,  when 
of  the  size  29,  30,  or  31  of  Charriere,  is  more  easy  to  intro- 
duce than  a  curved  one.  In  order  to  carry  it  into  the  bladder 
with  least  resistance,  it  should  be  passed  as  far  as  possible  in 
a  nearly  vertical  direction  toward  the  anus,  before  the  handle 
is  depressed ;  its  extremity  then  lies  not  only  in  front  of  the 
aperture  in  the  triangular  ligament,  but,  what  is  of  more 
importance,  below  it,  and  is  afterward  tilted  up  to  this  ori- 
fice by  depressing  the  handle  of  the  instrument  to  the  axis 
of  the  body.  The  tube  should  next  be  rotated  through  this 
aperture  like  a  corkscrew ;  and  during  this  process  its  point, 
which  is  made  a  little  eccentric  for  this  purpose,  revolves  in  a 


LITHOLAPAXY.  237 

small  circle  until  it  discovers  the  orifice.  A  common  difficulty 
in  introducing  a  catheter  or  lithotrite  results  from  depressing 
the  handle  prematurely,  by  which  the  beak  is  arrested  above 
the  aperture  in  the  ligament  instead  of  below  it.  This  error 
should  be  carefully  avoided  in  introducing  the  large  straight 
tube,  which  so  fills  the  urethra  that  it  needs  every  advan- 
tage in  traversing  its  less  yielding  parts.  Indeed,  it  is  not 
superfluous  to  say  that  even  a  free  use  of  oil  injected  with  a 
syringe  both  into  the  urethra  and  into  the  tube  may  some- 
times determine  the  question  of  the  passage  of  the  larger 
sizes.  And  yet,  with  these  precautions,  the  whole  manoeuvre 
is  a  very  easy  one.  Before  introducing  the  tube,  the  calibre 
of  the  urethra  is  ascertained  by  a  common  olive-pointed  elas- 
tic bougie,  or  a  sound.  I  have  not  found  much  advantage  in 
trying  to  dilate  it,  unless  at  the  moment  of  tlie  operation, 
by  incising  the  meatus,  which  is  the  narrowest  part,  or  by 
"divulsing"  a  stricture  when  it  exists.  Such  preliminary 
enlargement  of  the  contracted  canal,  unless  especially  contra- 
indicated,  suggests  itself. 

But  there  is  another  important  measure  that  does  not  sug- 
gest itself,  and  yet  deserves  careful  attention.  In  order  to 
protect  the  bladder  from  over-distention,  the  first  movement 
of  the  aspirator  should  be  to  withdraw  water  from  it,  and  not 
to  inject  water  into  it.  This  cannot  be  too  strongly  empha- 
sized. As  a  preliminary  to  this  precaution,  the  surgeon  ascer- 
tains exactly  the  capacity  of  the  bladder.  For  this  purpose 
it  should  be  emptied  by  a  catheter,  and  tepid  water  slowly  in- 
jected, until  the  fluid  is  forcibly  expelled  between  the  cath- 
eter and  the  loosely  grasped  urethral  walls.  This  reaction 
of  the  organ,  which  anaesthesia  does  not  prevent,  may  be 
relied  on  to  furnish  a  sufficiently  accurate  indication  of  the 
size  of  its  cavity.  If  the  fluid  be  now  drawn  off  and  measured, 
the  same  amount  may  be  safely  reinjected  through  the  large 
tube,  which  is  next  to  be  introduced,  the  injected  fluid  being 


238  LITHOLAPAXY. 

retained  in  the  bladder  by  a  tape  tied  round  the  penis,  with 
the  thumb  or  a  cork  at  the  extremity  of  the  tube.  Here  is, 
I  think,  a  critical  moment  of  the  operation ;  because  if  the 
contents  of  the  bulb  are  added  to  those  of  the  already  dis- 
tended bladder,  the  organ  may  be  over-stretched.  It  should 
not  be  forgotten,  therefore,  that  the  elastic  bulb,  before  it  is 
attached  to  the  tube,  should  be  compressed  until  the  sides 
meet,  in  order  that  its  first  action  may  he  to  ivithdraw  from  the 
bladder f  hy  its  expansion,  such  an  amount  of  fluid  as  can  be 
reinjected  with  safety.  The  present  instrument  holds  ten 
ounces ;  by  compression  it  loses  five  ounces.  This  amount 
would  then  be  aspirated  from  the  bladder  by  its  first  expan- 
sion, after  which  the  usual  pumping  action  displaces  only 
about  two  ounces  of  fluid  at  each  stroke,  and  can  hardly 
injure  the  bladder.  In  order  to  direct  attention  to  the  impor- 
tance of  compressing  the  elastic  bulb,  a  clamp  is  provided 
with  the  instrument  to  compress  the  bulb  before  it  is  attached 
to  the  tube.  Other  details,  relating  especially  to  the  signs  and 
avoidance  of  obstruction,  may  be  found  elsewhere.  Briefly, 
when  fragments  are  still  felt,  and  yet  cease  to  fall  into  the 
trap,  there  is  either  obstruction,  —  which  usually  occurs  in 
the  tube,  and  should  be  removed  by  compressing  the  bulb  or 
introducing  the  rod,  —  or  the  fragments  are  too  large  to  pass 
the  tube,  and  need  further  crushing.  In  respect  to  the  time 
occupied  by  the  whole  operation,  I  would  suggest  that  if  the 
surgeon  will  crush  the  stone  as  usual  and  then  remove  the 
fragments,  he  will  probably  find  his  patient  to  be  still  in  so 
good  a  condition  that  he  will  be  tempted  again  to  introduce 
the  lithotrite,  followed  by  the  tube.  At  the  end  of  half  an 
hour  or  more  he  will  have  repeated  this  several  times,  and 
will  then  find  that  the  stone,  if  of  average  dimensions,  has 
been  evacuated.  He  will  also  find,  in  a  common  case,  that 
the  patient  is  no  worse  for  the  operation. 

As  these  remarks  apply  chiefly  to  the  mechanical  part  of 


LITHOLAPAXY.  239 

lithotrity,  —  an  operation  which,  indeed,  depends  more  than 
any  other  for  its  success  upon  a  careful  and  economical  adap- 
tation of  its  instruments  to  their  employment,  —  a  few  obser- 
vations may  be  here  added  respecting  the  lithotrite.^ 

It  is  very  desirable,  during  a  long  operation,  to  prevent  the 
impaction  of  the  lithotrite,  which  interferes  with  crushing, 
and  sometimes  injures  the  neck  of  the  bladder.  This  may  be 
effected  by  raising  the  floor  of  the  female  blade,  and  by  add- 
ing lateral  notches  to  the  male  blade,  which  should  be  also 
provided  with  a  central  septum  at  the  heel.  The  lateral 
grooves  for  the  male  blade  should  also  extend  through  the 
heel  of  the  female  blade.  I  am  persuaded  that  the  simplest 
movement  for  locking  a  lithotrite  is  a  quarter  rotation  of  the 
right  wrist,  without  displacing  the  fingers  of  either  hand. 
Further,  it  seems  not  to  be  always  remembered  by  surgeons 
that  the  "  rapidity  "  of  a  lithotrite  depends  upon  the  inclina- 
tion of  its  screw  thread ;  and  that  while  the  slowest  screw 
gives  most  power  and  requires  the  strongest  blades,  "  rapidity" 
sacrifices  power.  In  the  longer  and  more  rapid  operation 
now  contemplated,  larger  and  stronger  blades  than  have  been 
commonly  employed,  and  which  also  better  protect  the  bladder 
than  do  the  latter,  seem  to  me  desirable. 

I  have  elsewhere  said  that  the  blades  of  a  lithotrite  should 
be  as  nearly  at  right  angles  with  the  shaft,  and  their  floor  as 
straight,  as  is  compatible  with  their  convenient  introduction 
into  the  bladder.  Many  instruments  are  made  with  oblique 
blades,  which  are  also  so  rounded  at  the  heel  as  to  curve 
their  floor.  This  is  a  mistake.  A  cubical  stone,  for  instance, 
would  exactly  fit  a  right-angled  lithotrite.  But  when  the 
same  blades  are  made  oblique,  at  an  angle  for  example  of 
forty-five  degrees  with  the  shaft,  then  in  order  to  grasp  the 
same  stone  they  must  not  only  be  opened  wider,  but  they  will 

1  The  aspirating  siphon  and  the  lithotrite  have  been  made  by  Weiss 
and  Son,  with  great  mechanical  perfection. 


240  LITHOLAPAXY. 

not  reach  so  far  out  upon  the  stone.  In  other  words,  the  size 
of  their  grasp  rapidly  diminishes  with  their  obliquity.  They 
must  be  opened  wider,  and  they  seize  less  of  the  stone. 
Their  power  also  diminishes,  because  if  they  are  made  longer 
with  the  view  of  preserving  their  grasp,  their  increasing  lever- 
age increases  friction  in  the  slide.  This  is  readily  seen  by 
increasing  the  obliquity  until  they  reach  the  line  of  the  stem 
of  the  instrument.  The  shaft  and  blades  are  then  in  a  con- 
tinuous straight  line,  and  they  merely  roll  the  fragment 
between  them.  The  latter  acts  only  as  a  wedge  to  separate 
them,  while  the  friction  of  the  slide  is  at  its  maximum.  In 
other  words,  right-angled  blades  crush  best  and  wedge  least. 
Oblique  blades,  on  the  contrary,  wedge  more  and  crush  less, 
and  the  depth  of  their  grasp  is  also  less.  And  what  is  here 
true  of  the  whole  blade  is  true  of  any  part  of  it,  —  the  heel, 
for  example,  which  should  not  be  oblique  nor  much  rounded, 
but  as  nearly  at  right  angles  with  the  shaft  and  with  as 
straight  a  floor  as  is  compatible  with  its  convenient  intro- 
duction. It  is  only  the  difficulty  of  introducing  right-angled 
blades  that  compels  us  to  make  them  a  little  oblique  and 
curved.  But  the  slanting  and  hooked  blades,  sometimes  still 
made,  act  at  great  disadvantage.  It  may  be  added  that  the 
tip  of  the  female  blade  should  be  bevelled,  so  that  (if  we 
compare  it  to  a  bent  finger)  it  may  impinge  against  the 
upper  wall  of  the  prostate,  while  passing  it,  rather  with  its 
pulp  than  with  its  nail. 

In  conclusion,  it  may  be  said  that  a  small  stone  does  not 
usually  entail  a  serious  operation  of  any  kind.  On  the  other 
hand,  a  large  stone  docs.  It  may  be  better  to  resort  to  litho- 
tomy in  the  case  of  a  large  stone,  with  a  diseased  bladder  or 
kidney,  however  fatal  the  former  operation  may  be  in  such 
cases.  But  there  has  hardly  been  any  material  change  of 
late  years  in  the  operation  of  lithotomy,  unless  it  be  in  a 
greater  attention  to  cleanliness  and  in  the  general  treatment 


LITHOLAPAXY.  241 

of  the  patient.  It  is  certain  that  no  bona  fide  Lister  dressing 
can  be  applied  to  the  wound.  The  danger  also  of  haemor- 
rhage remains  the  same  as  heretofore.  So  that  I  think  any 
very  great  increase  in  the  percentage  of  recoveries  from 
lithotomy  would,  perhaps,  result  chiefly  from  a  resort  to  the 
operation  in  more  favorable  cases  than  formerly,  —  by  which 
I  mean  in  certain  cases  of  stone  which  have  been  of  late 
relegated  to  lithotrity,  and  which  might  as  well  be  sub- 
jects for  experiment  with  the  operation  now  proposed,  as 
for  lithotomy. 

The  question  then  presents  itself  thus :  — 

1.  Whether,  when  any  stone,  large  or  small,  has  been 
crushed,  it  is  not  better  to  distend  the  urethra  to  its  natural 
limits,  and  remove  the  detritus  at  once  by  a  few  strokes  of 
the  siphon,  than  to  leave  it  to  be  expelled  through  the  con- 
tracted urethra  by  the  unaided  and  comparatively  ineffectual 
efforts  of  the  bladder. 

2.  Whether,  by  thus  assisting  the  bladder,  we  may  not  so 
increase  the  amount  evacuated,  and  so  diminish  the  time  of 
the  operation,  that  it  may  be  possible  by  the  method  now 
proposed  to  treat  with  success  larger  stones  than  hereto- 
fore by  lithotrity. 


16 


242  LITHOLAPAXY. 


LITHOLAPAXY.i 

To  THE  Editor: 

The  Lancet  of  February  1  contains  a  paper  by  Sir  Henry 
Thompson,  entitled  "  A  Lecture  on  Lithotrity  at  one  or  more 
Sittings."  In  another  communication,  February  15,  he  prom- 
ises to  give  his  views  more  completely  "  in  the  fifth  edition  " 
of  his  Clinical  Lectures  "  now  going  through  the  press,"  The 
publication  of  this  volume  will  be  looked  for  with  the  more 
interest  because  the  Lecture  on  Lithotrity  fails  to  give  a  clear 
exposition  of  the  author's  existing  views.  It  mixes  new  and 
old  ideas,  its  tendency  being  to  obliterate  rather  than  define 
the  line  between  what  has  been  done  by  lithotrity  hitherto 
and  what  can  be  accomplished  now,  leaving  the  reader  un- 
certain how  far  Sir  Henry  discriminates  between  the  new  and 
old  method. 

The  new  operation  enlarges  the  range  of  lithotrity,  and 
encroaches  upon  that  which  has  hitherto  been  regarded  as 
belonging  exclusively  to  lithotomy.  This  is  all  I  claim  for  it. 
Cases  can  be  relieved  by  litholapaxy  which  would  not  have 
been  treated  by  the  old  lithotrity ;  as,  for  instance,  one  case 
where  eighteen  hundred  and  two  grains  of  soft  stone  were  re- 
moved at  three  sittings,  —  one  of  nearly  four  hours'  duration, 
the  patient  travelling  home  four  days  afterward.  Such  a 
result,  till  now  wholly  unprecedented,  would  have  been  before 
regarded  as  bordering  on  the  impossible.  Experience  alone 
can  decide  the  limits  of  the  new  operation.^     I  am  surprised 

1  The  Lancet,  May  17,  1879. 

2  So  early  as  1846  Sir  Philip  Crampton  said  :  "  It  appears,  then,  that 
cystotomy  and  lithotrity  are  not  to  be  considered  as  rivals,  and  that  the 
question  as  to  which  of  these  operations  should  be  the  rule  and  which 
the  exception  should  never  be  brought  into  discussion ;  each  operation 


LITHOLAPAXY.  243 

that  Sir  Henry  should  attribute  to  me  a  disposition  "  to  make 
the  rule  absolute  to  remove  at  one  sitting  an  entire  stone,  no 
matter  how  large  it  may  be,  or  what  may  be  the  condition  of 
the  patient."  He  adds:  "Invariable  conformity  to  such  a 
rule,  I  do  not  hesitate  at  the  outset  to  say,  will  lead  to  results 
which  though  often  successful  will  not  seldom  be  disastrous." 
This  is  obvious. 

In  attempting  to  identify  the  old  operation  with  the  new, 
Sir  Henry  relies  mainly  upon  his  having  used  Clover's  form  of 
Crampton's  instrument,  with  which  Sir  Philip,  before  1846, 
drew  "  upwards  of  two  drachms  of  pulverized  calculus  at  once 
from  the  bladder."  ^  He  dwells  much  on  what  he  calls  "  that 
useful  instrument,  the  aspirator  of  Clover,"  It  is  figured  in 
his  former  works  with  half-a-dozen  differently  curved  catheters 
attached  to  it.  He  now  figures  it  (see  Lancet)  with  "  a  slight 
modification,"  as  he  says,  based  upon  what  he  calls  a  "hint" 
from  my  "  aspirator."  It  is  quite  extraordinary  that  Sir 
Henry  should  claim  such  efficiency  for  Clover's  apparatus. 
Except  in  cases  where  the  prostate  is  so  enlarged  that  the 
bladder  retains  even  sand,  his  is  the  only  voice,  so  far  as  I 
know,  that  has  spoken  in  its  favor.^ 

has  its  special  province,  the  boundaries  of  which  (if,  indeed,  they  admit 
of  being  fixed  at  all)  can  be  determined  only  by  a  comparison  of  a  vast 
collection  of  facts  carefully  noted,  and  above  all  faithfully  reported  and 
properly  authenticated."  (Dublin  Quarterly  Journal  of  Medical  Science, 
1846,  vol.  i.  p.  25.) 

1  Dublin  Quarterly  Journal  of  ]\Iedical  Science,  1846,  vol.  i.  p.  22. 

2  For  the  information  of  those  who  have  not  seen  my  paper,  I  here 
cite  the  latest  authorities  on  this  point :  — • 

We  may  here  say,  without  fear  of  being  accused  of  exaggeration,  that 
evacuating  injections  practised  after  sittings  of  lithotrity  have  no  apology 
for  their  use.  The  lohole  surgical  arsenal  invented  for  their  performance  is 
absolutely  useless.  .  .  .  It  should  he  ivell  understood  that  the  best  of  evacua- 
ting catheters  is  worthless.  —  Demarquay  et  Cousin  :  Nouveau  Diction- 
naire  de  Me'decine  et  de  Chirurgie  Pratique,  pp.  693,  694.     (Paris,  1875). 

Having  used  it  [Clover's  apparatus]  very  frequently,  I  would  add  that 
it  is  necessai'y  to  use  all  such  apparatus  with  extreme  gentleness,  and  / 


244  LITHOLAPAXY. 

Clover's  instrument  is  a  very  good  bladder-washer.  But  as 
an  evacuator  of  anything  but  sand  and  minute  fragments  that 
can  also  pass  the  urethra  without  it,  it  is  unequivocally  worth- 
less. It  cannot  be  otherwise.  Its  size,  with  its  collar,  is  only 
No.  21  French  calibre,  through  which  nothing  of  importance 
can  escape  from  the  bladder.  In  fact,  to  adapt  it  to  the  new 
system,  Sir  Henry  has  been  compelled  to  enlarge  its  calibre 
from  21  to  26.  Again,  the  bulb  of  Clover  is  so  weak  that  in 
a  vertical  position  it  cannot  expand  to  its  own  full  dimen- 
sions ;  much  less  can  it  aspirate  effectively.  For  this  slender 
bag  Sir  Henry  has  now  substituted  a  bulb,  "  stiff,"  as  he  de- 
scribes it,  like  mine.  The  short  curve  which  I  had  selected 
from  the  arsenal  of  old  catheters  and  sounds  for  the  end  of  my 

■prefer  lo  do  witJiout  it,  if  possible.  —  Sir  Henry  Thompson  :  Practical 
Lilhotrity  and  Lithotomy,  p.  215  (1871). 

All  these  evacuating  catheters  are  little  employed.  They  require  frequent 
and  long  manoeuvres,  which  are  not  exempt  from  dangers ;  besides  they 
give  passage  as  a  rule  only  to  dust,  or  to  small  fragments  of  stone,  ichich 
would  have  escaped  of  themselves  without  inconvenience  to  the  urethra.  — • 
M.  VoiLLEMiER :  Dictionnaire  Encyclopedique  des  Sciences  Medicales, 
p.  733  (1869). 

In  short,  the  "  evacuating  apparatus "  and  the  evacuating  method, 
hitherto  employed  do  not  evacuate.  This  fact  is  beyond  question. 
BiGELOw:  Liiholapaxy,  etc.,  pp.  6,  7  (London,  1878). 

Sir  Henry  Thompson  also  testifies  to  the  ineflRciency  of  Clover's  instru- 
ment by  admitting  that  when,  in  the  old  lithotrity,  he  wanted  to  evacuate 
the  fragments  as  rapidily  as  possible,  he  employed  several  sittings.  "  It 
is  desirable,"  he  says  (Lancet,  January  8,  1876,  p.  38),  "  to  treat  any 
cystitis  that  may  occur  during  the  course  of  the  sittings,  especially  if  it 
is  severe,  by  freely  crushing  the  stone  without  delay.  .  .  .  Under  these 
circumstances,  I  place  the  patient  under  the  influence  of  ether,  crush 
freely  aU  the  large  and  sharp  pieces,  and  wash  out  the  debris  with  Mr. 
Clover's  aspirator." 

But  as  Clover's  instrument  evacuates  inefficiently.  Sir  Henry  is  com- 
pelled to  add  :  "  If  some  large  pieces  still  remain  after  the  fresh  crushing, 
the  former  symptoms  of  cystitis  re-appear  in  two  or  three  days,  and  may 
be  again  relieved  by  another  sitting, — this  time  altogether  or  nearly  so,  as 
a  succeeding  crushing  will  no  doubt  dispose  of  the  principal  part  of  the 
stone,  and  leave  at  all  events  no  considerable  fragments." 


LITHOLAPAXY.  245 

curved  tube  he  now  discovers  to  be  the  "  more  generally  useful 
form."  1  He  lias  also  adopted  my  terminal  trap  below  the 
bulb.  With  these  modifications,  he  gives  what  he  entitles 
"  an  admirable  illustration  of  the  existing  method."  This 
flattering  adoption  of  the  essential  features  of  ray  plan,  which 
Sir  Henry  calls  "  taking  a  hint,"  is  rather  like  taking  the  ap- 
paratus. If  not,  let  Sir  Henry  endeavor  to  evacuate  a  stone 
of  moderate  size  with  "  Clover's  original  instrument "  as  now 
"  slightly  modified  "  by  him,  omitting  only  the  "  stiff "  bulb 
and  enlarged  tube.'"^ 

Although  my  pump  acts  perfectly,  the  operator  will  doubt- 
less modify  it  a  little  to  suit  himself,  adopting  the  necessary 
conditions  of  an  adequate  exhaust  of  some  sort,  an  adequate 
evacuating  tube,  and  an  efficient  trap.  I  find  also  that  an 
elastic  tube  interposed  between  the  bulb  and  the  bladder,  to 
avoid  the  jar  of  pumping,  is  desirable. 

But  what  I  insist  upon,  as  characterizing  the  new  litlio- 
trity,  is  — 

1.  A  practical  recognition  of  the  tolerance  of  the  bladder, 
which  is  far  less  sensitive  to  instruments  than  to  fragments, 

1  Hitherto  Sir  Henry  has  designated  as  the  most  useful  form  a  squarely 
cut  extremity.  "  In  most  cases,"  he  says,  "  the  best  kind  is  that  which 
is  cut  transversely  at  the  distal  end  "  (The  Diseases  of  the  Prostate,  etc., 
p.  337,  fourth  edition,  Philadelphia,  1873).  Such  an  extremity  is  really 
the  worst,  because  it  is  at  once  closed  by  the  bladder. 

2  Sir  Henry  does  not  seem  to  appreciate  the  full  use  of  a  large  tube. 
This  is  shown  by  his  figure  of  the  "  modified  "  instrument  (See  Lancet, 
February  1),  where,  although  the  calibre  of  the  evacuating  tube  is  26, 
its  hole  for  the  admission  of  fragments  is  but  little  more  than  half  its 
diameter.  Where  lies  the  utility  of  so  large  a  tube,  if  only  small  frag- 
ments can  get  into  it  ?     This  hole  is  a  relic  of  the  Clover  insti'ument. 

As  regards  the  size  of  the  tube,  the  operator  can  fairly  take  advantage 
of  the  f  uU  size  of  the  urethra.  The  larger  the  tube,  the  larger  will  be  the 
fragments  released.  I  have  employed,  without  any  objectionable  result, 
a  30  French  calibre,  often  31 ;  and  I  prefer  a  straight  tube.  Although 
these  largest  sizes  are  not  essential  to  the  operation,  they  admit  many 
fragments  that  would  otherwise  have  to  be  crushed. 


246  LITHOLAPAXY. 

with  the  obvious  corollary  that  when  the  operator  crushes  a 
stone  it  is  better  to  remove  the  fragments  by  protracting 
the  operation  than  to  leave  them,  —  as  has  been  hitherto  the 
usual  practice  of  distinguished  operators,  including  Sir  Henry 
Thompson ;  and  — 

2.  The  use  of  a  tube  large  enough  to  afford  an  easy  passage 
from  the  bladder,  not  (as  with  Clover's  instrument)  for  sand, 
which  does  not  need  it,  but  for  detritus,  which,  owing  to  its 
size  or  quantity,  would  not  pass  the  urethra  without  it, —  this 
being  an  application  of  Otis's  discovery  of  the  previously  un- 
recognized capacity  of  the  urethra,  of  which  the  meatus  is  the 
narrowest  part. 

This  is  not  in  accordance  with  the  former  teaching  of 
lithotritists.  At  the  late  litrotrity  meeting  of  the  Medico- 
Chirurgical  Society  there  was  no  question  about  the  traditional 
few  minutes,^  as  the  limit  of  time  beyond  which  it  is  not 
usually  safe  for  the  lithotritist  to  try  the  endurance  of  an 
average  bladder.  The  error  is  a  natural  one.  Surgeons  have 
hitherto  attributed  to  instruments  of  polished  metal  the  dam- 
age really  due  to  the  roughness  of  fragments.  With  Sir  Henry 
Thompson,  they  believed  that  "  the  mere  sojourn  of  the 
instrument  in  the  bladder  is  a  source  of  irritation  precisely 
corresponding  to  the  time,  within  certain  limits,  it  continues 
there.  Anything,  therefore,  that  will  diminish  the  time  of 
the  operation,  and  the  amount  of  movement  and  concussion, 
will  necessarily  give  a  greater  prospect  of  success,"  ^  This 
mistake  prevailed  for  half  a  century,  because  the  real  cause 
of  the  injury  could  not  be  ascertained.  There  was  absolutely 
no  way  to  extract  fragments  large  or  abundant  enough  to 

^  A  sojourn,  say  of  two  minutes,  in  the  bladder,  which  I  will  allow 
you,  although  you  know  I  do  not  occupy  so  much  time  myself.  —  Sir 
Henry  Thompson  :  Clinical  Lectures  on  Diseases  of  the  Urinary  Organs 
etc.,  p.  188  (Fourth  edition.     London,  1876). 

2  Clinical  Lectures,  etc.,  p.  172. 


LITHOLAPAXY.  247 

make  trouble,  and  to  show  what  would  be  the  behavior  of  the 
bladder  when  thus  relieved.  The  new  instrument  first  ac- 
complished the  evacuation  of  bulky  ddbris,  and  by  removing 
this  source  of  inflammation  disclosed  the  comparative  harm- 
lessness  of  the  lithotrite  and  the  pump.  The  discovery  of 
the  tolerance  of  the  bladder  could  have  been  made  in  no  other 
way.  What  Sir  Henry  Thompson  would  call  a  little  modifica- 
tion of  method  involved  an  important  difference  in  result, 
making  it  easy  to  accomplish  what  was  before  impracticable, 
—  a  trite  occurrence  in  the  history  of  inventions. 

There  can  be  no  doubt  about  Sir  Henry  Thompson's 
teaching.     So  lately  as  1876  he  writes :  — 

''You  heard  me  say  in  the  theatre  the  other  day  .  .  .  that  you 
should  not  encourage  the  early  passing  of  the  fragments.  They 
rest  at  the  bottom  of  the  bladder.  I  usually  keep  the  patient  in 
bed,  and  pretty  much  on  his  back,  for  thirty-six  hours  or  so,  after- 
wards. He  should  at  all  events,  for  that  period  of  time,  pass  urine 
in  that  position,  so  that  the  sharp  angular  fragments  are  left  at 
the  bottom  of  the  bladder  and  are  not  forced  into  the  urethra."  ^ 

With  unparalleled  opportunities  for  observation,  Sir  Henry 
seems  to  have  been  well  satisfied  with  the  old  lithotrity  and 
its  instruments.  In  the  lecture  to  which  he  refers  for  an  expo- 
sition of  his  latest  views,  he  says  :  — 

"I  do  not  mean  to  say  that  any  striking  novelties  in  the  instru- 
ments, or  in  the  system  of  operating,  have  recently  been  achieved. 
The  mechanical  procedure  has  probably  long  been  too  nearly  per- 
fect to  permit  us  to  expect  results  of  that  kind."  ^ 

When  this  conservative  view  was  again  expressed  at  the 
lithotrity  meeting  of  the  Medico-Chirurgical  Society  in  1878,^ 
it  elicited  nothing  from  Sir  Henry  concerning  the  tolerance 
of  the   bladder  to   instruments,  the  advantage  of  removing 

1  Clinical  Lectures,  etc.,  p.  188. 

■■^  Clinical  Lecture,  Lancet,  January  8,  1876. 

3  The  Lancet,  March  16,  1878,  p.  385. 


248  LITHOLAPAXY. 

all  fragments,  or  any  other  essential  feature  of  the  new 
operation. 

I  may  here  allude  to  a  small  matter.  Sir  Henry  insists 
upon  the  importance  of  making  the  movements  of  the  bulb 
keep  time  with  the  respiration  of  the  patient.  I  think  this 
will  be  found  both  unnecessary  and  impracticable.  The  first 
part  of  any  long  aspiration,  whether  it  is  or  is  not  synchronous 
with  the  breathing,  suffices  to  clog  the  orifice  of  the  tube  with 
debris  ;  the  last  part  of  the  aspiration  is  then  useless.  Nor 
does  a  "  stiff "  bulb  need  to  be  aided  by  the  diaphragm  of  the 
patient.  Nor  need  danger  be  apprehended  from  any  expul- 
sive effort  to  which  the  bladder  is  accustomed,  like  respiration, 
cough,  or  even  vomiting.  In  fact,  this  last  is  not  unusual 
with  an  anaesthetic.     I  let  the  water  off  while  it  continues. 

Although  a  long  stroke  is  occasionally  useful,  I  commonly 
pump  at  the  rate  of  about  twice  in  three  seconds,  moving  only 
about  two  ounces  of  water  back  and  forth.  The  main  diffi- 
culty is  to  find  for  the  extremity  of  the  tube  the  best  place  for 
gathering  fragments,  and  to  prevent  its  obstruction,  whether 
by  fragments  or  by  the  bladder.  This  somewhat  nice  adjust- 
ment is  experimental,  and,  I  think,  is  easiest  when  the  left 
hand,  holding  the  evacuating  tube,  rests  on  the  pubes.  The 
manipulation  is  provided  for  in  my  instrument  by  the  inter- 
vention, between  the  evacuating  tube  and  the  bulb,  of  an 
elastic  tube  eight  inches  long.  If  the  operator  prefers,  it 
may  be  shorter ;  my  first  one  was  only  two  inches  long.  The 
facility  and  delicacy  of  the  manipulation,  it  is  needless  to 
say,  are  greatly  impaired  if  the  bulb  be  rigidly  attached  to 
the  evacuating  tube,  as  in  Clover's  apparatus  and  Sir  Henry 
Thompson's  figure,  —  especially  if,  as  there,  it  is  placed  above 
the  tube. 

In  my  present  method  of  evacuating  the  debris,  the  bulb 
full  of  water  is  coupled  with  the  evacuating  tube  introduced 
into  the  empty  bladder;   and  when  the  pump  is  in  action, 


LITHOLAPAXY.  249 

water  is  added  to  distend  the  bladder,  if  its  walls  prove  to  be 
slack  enough  to  fall  into  the  eye  of  the  tube  and  obstruct 
it.  The  earlier  cases  naturally  occupied  more  time  than  is 
now  necessary  ;  but  I  still  find,  as  at  first,  that  the  most 
time  is  spent  in  searching  for  and  removing  the  last  frag- 
ment, and  in  incidental  delays,  —  not  in  evacuating  the  mass 
of  debris,  which  is  drawn  out  with  surprising  rapidity. 
With  ether,  rapid  surgery  has  become  less  essential ;  and 
lithotrity  is  now,  perhaps,  less  than  any  other  surgical  opera- 
tion, to  be  performed  against  time.  I  doubt  whether  the 
hurried  operation  mentioned  by  Sir  Henry  Thompson  would 
bear  frequent  repetition  even  by  himself.  There  would  seem 
to  be  need  rather  of  deliberation  than  of  haste.  A  remainins; 
fragment  may  be  easily  overlooked ;  and  in  less  skilled  hands 
haste  might  be  mischievous.  Removing  a  stone  of  one  hun- 
dred and  twenty  grains,  with  two  lithotrites  and  an  assist- 
ant* to  clear  them,  is  mainly  the  operation  of  Fergusson,  who 
relied  for  evacuation  on  repeated  withdrawals  of  the  loaded 
Instrument. 

Litholapaxy  is  now  no  novelty  in  America ;  and  its  success 
here  will,  I  think,  recommend  it  elsewhere.  Allow  me  to  add 
a  few  recent  examples. 

An  operation  which  I  performed  January  26,  in  the  case 
of  a  medical  gentleman  aged  sixty-seven  years,  lasted  fifty 
minutes,  and  consisted  of  two  crushings,  occupying  fifteen 
minutes ;  three  evacuations  of  fragments,  nine  minutes ; 
changes,  and  other  delay,  twenty-six  minutes.  Two  hundred 
and  sixty  grains  of  phosphatic  stone  were  thus  removed.  The 
patient  had  no  trouble  from  the  operation,  and  on  the  thir- 
teenth day  went  home  to  the  country,  well.  There  were  no 
fragments  left  in  the  bladder. 

In  another  case,  February  10,  that  of  a  man  aged  fifty 
years,  one  diameter  of  the  stone  measured  If  inches.  The 
operation  continued  one  hour  and  twenty-one  minutes.     The 


250  LITHOLAPAXY. 

crusliings  occupied  twenty  minutes ;  the  evacuation  of  frag- 
ments, thirty ;  while  the  changes,  etc.,  were  recorded  at 
thirty-one  minutes.  Three  hundred  and  two  grains  of  hard 
oxalate  calculus  were  crushed  and  drawn  out,  —  with  some 
delay  in  the  operation,  due  to  fragments  lodged  behind  a  high 
prostate.  I  was  unable  to  break  the  stone  with  Charridre's, 
or  rather  Collin's,  instrument.  The  patient  had  no  unfa- 
vorable symptoms,  hardly  a  trace  of  blood,  and  no  fragments 
were  left. 

This  case,  which  involves,  so  far  as  I  know,  the  largest  hard* 
stone  yet  evacuated  at  one  sitting,  is  an  example  of  what  can 
be  done  by  the  new  process.  In  evacuating  such  stones,  it 
need  only  be  said  that  the  smaller  the  tube  the  more  mi- 
nutely must  the  fragments  be  broken,  and  the  greater  will 
be  the  liability  to  obstruction.  Small  stones,  common  in 
these  later  days  of  lithotrity,  especially  soft  ones,  are  not 
infrequently  crushed  at  one  sitting,  by  any  lithotrite,  without 
ether,  and,  if  reduced  to  sand,  may  really  need  no  tube  to 
evacuate  them. 

The  following  case  is  as  good  a  test  of  the  new  operation  as 
I  could  wish. 

The  patient,  aged  thirty-three,  entered  the  hospital  October 
31,  about  four  months  and  a  half  ago.  His  condition  was  so 
bad  that  it  was  thought  unadvisable  to  attempt  any  operation, 
even  lithotomy.  The  urine  was  ammoniacal  and  fetid,  always 
containing  a  large  quantity  of  blood,  —  also  pus  and  mucus  to 
the  amount  sometimes  of  nearly  one  half,  by  measurement. 
Micturition  was  very  frequent,  occurring  at  intervals  of  from 
ten  minutes  to  half  an  hour,  day  and  night,  during  much  of 
this  time.  The  straining  was  excessive,  ineffectual,  and  pro- 
ductive of  great  suffering.  Three  unsuccessful  attempts 
having  been  made  on  previous  days,  a  sound  was  first  intro- 
duced into  the  bladder,  under  ether,  November  10.  The 
next  day  the  temperature  rose  to  103°,  and  remained  there- 


LITHOLAPAXY.  251 

about  till  the  fourth  day,  when  another  complication  presented 
itself.  The  left  knee  became  suddenly  inflamed  and  swol- 
len. It  has  remained  so  ever  since.  During  the  next  two 
months  the  temperature  ranged  from  100°  to  102°  daily, — 
afterward  slowly  receding,  though  the  other  symptoms  did 
not  abate. 

I  saw  the  case,  for  the  first  time,  March  7.  With  so  dis- 
eased and  irritable  a  bladder,  it  was  evident  that  litholapaxy 
could  be  considered  only  as  an  experiment.  It  was  a  last 
resort,  being  perhaps  better  than  lithotomy.  Should  it  suc- 
ceed, it  would  testify  strongly  in  favor  of  the  new  method ; 
should  it  fail,  it  could  hardly  be  counted  against  it. 

On  the  9th  of  March  I  operated.  In  the  neighborhood  of 
the  triangular  ligament  an  obstruction  prevented  the  passage 
of  sounds  larger  than  a  No.  15  French  calibre.  After  snipping 
the  meatus,  this  obstruction  was  divulsed  by  Voillemier's 
instrument,  and  it  then  admitted  a  full-sized  lithotrite,  and  a 
straight  tube,  29  French,  for  which,  later  in  the  operation,  30 
was  substituted.  Two  hundred  and  forty  grains  of  stone 
were  now  slowly  and  carefully  removed  in  sixty-eight  min- 
utes. An  abundance  of  fiocculent  and  fibrinous  material  con- 
cealed the  fragments  when  lying  in  a  basin,  and  testified  to 
the  inflammation. 

At  4  p.  M.,  four  hours  after  the  operation,  the  temperature 
had  fallen  from  99°  to  96°.  In  eight  hours  more,  at  midnight, 
it  had  risen  to  103°  with  a  pulse  of  130,  where  it  remained 
through  the  second  day,  the  tongue  being  red,  smooth,  and 
dry.  A  general  pain  in  the  region  of  the  bladder  and  urethra 
required  opiates.  Yet,  on  the  third  day,  the  tongue  became 
moist,  with  a  light  coat,  the  temperature  had  fallen  to  99°,  and 
the  pulse  to  84.  This  improvement  still  continues.  The 
patient  has  had  no  such  comfort  for  many  months.  During 
the  first  week  after  the  operation  he  passed  his  water  six  times 
in  twenty-four  hours  almost  without  pain,  and  there  has  been 


252  LITHOLAPAXY. 

no  tenderness  over  the  bladder.  The  urine  contains  very  little 
sediment,  and  apart  from  the  knee,  which  remains  as  it  was, 
the  patient  is  rapidly  convalescing. 

I  have  only  to  add  a  few  words  regarding  the  new  lithotrite. 
Sir  Henry  does  not  seem  so  heartily  satisfied  with  mine  as  I 
could  wish,  nor,  in  fact,  with  anything  connected  with  the  new 
operation,  unless  possibly  its  results.  This  lithotrite,  he  says, 
is  '•  surely  some  resuscitated  relic  of  the  early  history  of  litho- 
trity, .  .  .  reminding  him  very  forcibly  of  the  terrible  engines 
used  by  Heurteloup."  ^  The  present  tendency  of  London 
lithotrites  is  to  small  size,  because  it  has  been  believed  that 
the  smaller  the  instrument  the  less  the  danger.  With  long 
operations,  large  stones,  and  the  general  use  of  ether,  they 
will  again  be  larger.  With  size  we  gain  power.  There  is  no 
more  reason  for  employing  small  lithotrites  to  empty,  under 
ether,  an  average  bladder,  than  small  catheters  to  draw  the 
water.  In  fact,  the  surgeon  who  becomes  accustomed  to  the 
efficient  action  of  a  large  lithotrite  does  not  willingly  relin- 
quish it;  a  little  more  care  is  necessary  in  introducing  it, 
but  if  non-impacting  it  need  not  be  withdrawn,  loaded  with 
sharp  fragments,  through  the  neck  of  the  bladder,  at  short 
intervals,  to  be  cleaned  by  an  assistant. 

My  new  lithotrite  proves  to  be  very  efficient,  and  I  am 
recently  indebted  to  London  makers  (Weiss  and  Son)  for  an 
instrument  that  works  ])erfectly.  It  is  a  good  size  for  gen- 
eral use ;  a  smaller  one,  if  preferred,  may  be  used  in  special 
cases.  This  instrument  is  non-impacting,  and  keeps  clean  in 
the  bladder  for  an  indefinite  time.  Its  rounded  tip  protects 
the  bladder  in  a  protracted  operation,  —  as  it  also  does  the 
prostate  during  introduction.  For  the  old  wheel,  which  hurts 
the  hand  in  long  crushing,  the  ball  is  a  welcome  substitute; 

1  Of  Ileurteloup's  operation  Crampton  says :  "  Nothing  could  exceed 
the  dexterity  and  skill,  unless  it  be  the  gentleness,  with  which  it  was  per- 
formed."    (Dublin  Quarterly  Journal  of  Medical  Science,  vol.  i.,  p.  17.) 


LITHOLAPAXY.  253 

and  unless  the  human  hand  undergoes  some  modification  of 
what  are  now  its  easiest  movements,  the  system  of  a  right- 
hand  lock^  here  first  employed,  must,  as  I  believe,  whatever 
be  the  size  of  the  lithotrite,  supersede  in  time  any  previous 
method  of  locking. 

Your  obedient  servant, 

Henry  J.  Bigelow. 

Boston,  March  25,  1879. 


254  LITHOLAPAXY. 


LITHOLAPAXY.i 

To  THE  Editor: 

An  editorial  paragraph  in  the  "  Record  "  of  May  31  men- 
tions that  the  letter  from  Sir  Henry  Thompson  to  Professor 
Van  Buren,  which  appeared  in  the  previous  issue,  was  written 
for  publication. 

Sir  Henry's  reiterated  criticisms  of  lithotrites  should  not 
be  allowed  to  obscure  the  main  facts,  be  their  value  more  or 
less,  of  rapid  lithotrity,  —  which  means  long  sittings  for  the 
immediate  and  complete  evacuation  of  the  fragments  by  large 
tubes,  and  depends  upon  the  newly  discovered  tolerance  of  the 
bladder  to  the  smooth  surfaces  of  instruments ;  while  the  old 
lithotrity  meant  repeated  short  sittings  and  sharp  fragments 
left  in  the  bladder. 

The  size  of  a  lithotrite  has  little  to  do  with  litholapaxy. 
Stones  are  so  frequently  soft  and  small  that  a  small  lithotrite 
of  any  kind  may  be  large  enough.  Of  course  the  operator 
will  be  careful  not  to  break  such  a  lithotrite  upon  a  large  or 
hard  stone.  Like  other  lithotrites,  mine  is  made  in  various 
sizes.  It  is  not,  however,  the  large  lithotrite  that  I  have  de- 
sired to  bring  to  the  attention  of  surgeons,  but  the  new  lock, 
and  the  protective  and  non-impacting  blades,  designed  to  pro- 
mote safe  and  rapid  work  at  a  moment  when  the  hand  or  the 
attention  of  the  operator  is  fatigued  by  a  long  operation.  I 
prefer  a  large  lithotrite  if  it  possesses  these  qualities,  even  in 
dealing  with  common  calculi.  Sir  Henry  prefers  a  smaller 
one,  whether  it  clogs  or  not,  and  frequently  withdraws  it  to 
clean  it.  His  prejudice  against  a  large  instrument  is  con- 
nected with  a  life-long  and  erroneous  theory  that  the  dangers 
of  lithotrity  result  mainly  from  the  instruments  used  in  the 

^  The  Boston  Medical  and  Surgical  Journal,  June  19,  1879. 


LITHOLAPAXY.  255 

operation.  This  was  the  general  mistake  of  the  day.  It  was 
not  known  that  the  irritation  was  really  occasioned  by  the 
fragments  which  it  was  the  custom  to  leave  in  the  bladder. 
When  these  fragments  were  drawn  out  by  my  apparatus,  and 
that  source  of  danger  to  the  bladder  was  removed,  it  was 
found  that  the  instruments  themselves  did  but  little  harm. 
Sir  Henry,  perhaps,  might  long  ago  have  discovered  this  fact 
of  the  tolerance  of  the  bladder  to  instrumentation  if  he  had 
possessed  any  means  of  evacuating  it  thoroughly.  But  he 
had  only  Clover's  instrument,  the  tube  of  which  was  so  small 
(21  French)  that  it  drew  out  only  sand  and  left  the  fragments. 
Hence  his  error  and  failure  to  discover  the  new  facts  of  what 
is  now  known  as  rapid  lithotrity. 

Sir  Henry  devotes  the  last  half  of  his  letter  to  the  ex- 
pression of  creditable  sentiments  in  relation  to  his  attitude 
toward  surgical  progress.  A  little  explanation  may  be  here 
desirable. 

A  year  after  the  publication  of  my  paper,  he  published  a 
lecture  in  the  "Lancet"  (Feb.  1,  1879),  in  which  he  says: 
"  My  own  system  has  for  a  long  time  past  been  gradually 
inclining  to  the  practice  of  crushing  more  calculus  at  a  sit- 
ting, and  removing  more  debris  by  the  aspirator  than  I  for- 
merly did,"  —  which  might  very  well  be  true,  his  former 
sittings  having  been  limited  to  two  minutes  or  less  ;  but  the 
hindrance  to  his  "  removing  more  debris  "  was  the  small  size 
of  Clover's  tube.  The  editor  of  the  "  Lancet "  replied  (Feb- 
ruary 15)  :  "  We  cannot  close  our  eyes  to  the  fact  that  the 
views  advanced  in  his  lecture  of  the  1st  inst.  do  involve  an 
abandonment  of  his  old  position.  Lithotrity  as  hitherto  prac- 
tised by  him  and  lithotrity  as  recommended  and  performed 
by  Professor  Bigelow  are  different  operations,  and  based 
on  opposite  and  contradictory  principles."  This  "editorial 
observation  "  in  the  "  Lancet "  Sir  Henry,  curiously  enough, 
chooses  to  regard,  in  his  letter  published  in  the  "  Record," 


256  LITHOLAPAXY. 

as  "  adverse  criticism  of  himself  personally,  not  of  liis  mode 
of  operating." 

Sir  Henry's  position  will  now  be  understood.  It  is  in  this 
connection  that  he  expresses  the  opinion  that  the  terms  "  aban- 
donment of  position  "  and  the  like,  "  adapted  as  they  are  to 
military  men,"  do  not  accord  with  the  aims  of  men  who 
"  '  live  and  learn.'  ...  It  is  an  error,"  he  says,  "  to  look  for 
a  life-long  consistency  in  matters  of  opinion  from  men  who 
think  for  themselves."  The  world  will  not  question  the  right 
of  Sir  Henry  to  "  live  and  learn,"  nor  to  "  think  for  himself," 
but  only  the  propriety  of  his  claiming  to  have  originated  by 
"  thinking  for  himself "  ideas  he  has  learned  from  others. 

A  friend  has  to-day  sent  me  the  fifth  edition,  just  published, 
of  Sir  Henry's  "Diseases  of  the  Urinary  Organs."  I  find  that 
in  this  edition  Sir  Henry  both  honors  rapid  lithotrity  with  his 
indorsement  and  appropriates  as  his  own  its  essential  details. 
He  adopts  large  tubes,  increasing  the  ineffectual  catheter  of 
Clover  from  21  to  29,  which  latter  calibre  I  often  employ,  my 
smallest  tube  being  27,  my  usual  size  30,  and  the  largest  31. 
"You  are  first  to  introduce,"  he  says  (page  173),  "  an  evacu- 
ating silver  catheter  fitted  with  a  flexible  stylet,  —  in  size, 
say,  from  No.  14  to  No.  16,  English  scale,"  calibres  equivalent 
to  24  and  29  French.^  Here  being  the  essential  feature  of 
the  operation.  Sir  Henry  at  this  point  definitively  abandons 

1  Ilanderson's  comparative  scale,  from  which  these  equivalent  numbers 
are  taken,  is  made  by  Reynders  &  Co.,  New  York.  It  is  accurate,  and 
very  convenient  in  having  instead  of  holes  a  long  triangiilar  slit  like  a 
wire  gauge.  "  In  England,"  says  Sir  Heni-y  Thompson,  "  we  cannot  be 
said  to  have  a  uniform  scale ;  all  our  measurements  are  very  arbitrary. 
One  maker  has  one  scale,  and  another  another."  (Diseases  of  the  Uri- 
nary Organs,  1879,  p.  47.)  On  page  48,  however,  he  gives  a  scale,  of 
which  the  largest  size  14  is  the  equivalent  of  24;  and  this  corresponds 
to  Ilanderson's  scale  (New  York  Medical  Record,  1877,  p.  638).  The 
French  numbers  increase  more  rapidly  than  the  English.  Larger  cali- 
bres have  hitherto  been  but  little  known  either  in  France  or  England. 
The  main  point  is  the  necessity  of  enlarging  Clover's  tube. 


LITHOLAPAXY.  257 

"  consistency "  and  the  21  tube  of  his  previous  editions  in 
favor  of  "  large  evacuating  catheters  and  a  good  aspirator " 
(page  177).  Neither  of  these  he  used  before  I  described  them. 
This  gives  him  the  whole  key  to  rapid  lithotrity,  and  he  is 
able  to  accomplish  thorough  evacuation  at  once  by  prolonging 
the  sitting  till  evacuation  is  complete,  demonstrating  at  the 
saine  time  that  the  bladder  tolerates  instrumentation  if  the 
fragments  are  removed,  —  which  is  the  new  principle  that 
underlies  litholapaxy.  The  large  tube  once  appropriated, 
what  remains  is  easy.  The  aspiration  of  his  new  edition 
means  effectual  aspiration  with  large  tubes,  and  his  lithotrity 
becomes  rapid  lithotrity. 

A  comparison  of  this.  Sir  Henry's  present  practice,  with  his 
recent  opposite  teaching  of  frequent  repeated  crushings  —  each 
confined  to  a  few  minutes,  lest  the  polished  instrument  injure 
the  bladder,  but  leaving  the  bladder  nevertheless  to  struggle 
in  the  intervals  with  sharp,  broken  pieces  of  stone,  which  he 
had  no  means  of  extracting  -^ —  will  show  the  significance  of 
the  criticism  by  the  editor  of  tlie  "  Lancet."  ^ 

In  conclusion,  I  may  venture   to  hope  that  the  valuable 

example  set  by  Sir  Henry  in  accepting  large  tubes  will  aid 

in  doing   away  with  whatever  apprehension   still   exists   of 

danger  from  their  use. 

Henry  J.  Bigelow. 

1  The  Lancet  of  May  17  contains  a  letter  on  this  subject. 


17 


258  LITHOLAPAXY. 


LITHOLAPAXY.i 

To  THE  Editor: 

Dear  Sir,  —  Will  you  allow  me  to  correct  an  erroneous 
statement  contained  in  one  of  your  recent  editorial  articles 
upon  the  new  lithotrity  (vol.  xvi.,  Nos.  7  and  8)  ?  It  relates 
to  the  lithotrite  devised  by  me.  This  particular  instrument 
is  not  indispensable  for  the  performance  of  litholapaxy,  since 
almost  any  lithotrite  can  be  made  to  crush  the  stone,  —  the 
novel  and  essential  characteristic  of  the  new  method  being 
the  complete  evacuation  of  the  calculus  by  a  long  sitting  and 
a  large  catheter.  But  although  the  error  referred  to  is  unim- 
portant, it  should,  I  think,  be  corrected  in  deference  to  sur- 
geons who  use  my  non-impacting  instrument. 

The  writer  says,  referring  to  the  lock  of  this  lithotrite, 
"  The  liability  to  break  is  a  serious  objection.  .  .  .  Thompson's 
catch  cannot  be  broken  in  this  manner."  Now,  this  is  a  mis- 
take. My  instrument,  although  employed  by  myself  and 
others  upon  stones  both  large  and  hard,  has  never  been,  as 
your  writer  states,  "  broken."  Nor  do  the  parts  he  alludes 
to  (the  old  screw-blocks  of  Charriere  and  their  boxes)  differ 
in  strength  from  those  of  all  other  lithotrites,  inasmuch  as 
they  are  identical  in  all  of  them.  If  one  breaks,  others  must 
be  liable  to  the  same  accident. 

This  writer  has  misapprehended  a  trivial  occurrence,  inci- 
dentally mentioned  many  months  ago,  in  connection  with  the 
then  novel  method.  This  was  what  happened.  Tiemann  and 
Co.  borrowed  from  me,  for  examination,  a  lithotrite  just 
arrived,  one  of  the  first  of  my  instruments  made  in  Paris, 
and  lent  it  for  use.     The  French  workman,  to  whom  the  lock 

1  The  New  York  Medical  Record,  Sept.  27,  1879. 


LITHOLAPAXY.  259 

was  new,  had  miscalculated  the  width  in  this  combination 
of  the  Charriere  screw-blocks,  so  that  when  the  instrument 
was  locked  and  screwed  up  these  blocks  had  little  or  no  bear- 
ing. They  were  at  once  lifted  out  of  their  boxes,  just  as  they 
are  purposely  lifted  out  by  thumb  and  finger  when  they  need 
cleaning.  That  was  the  whole  of  it.  The  skilful  French 
maker,  annoyed  at  the  carelessness  of  his  workman,  made 
the  lithotrite  perfect  in  a  few  hours  ;  and  the  surgeon,  in 
whose  hands  the  defective  adjustment  revealed  itself,  ordered 
one  of  my  lithotrites  from  Weiss. 

The  error  here  corrected  does  not  impair  the  general  excel- 
lence of  the  other  criticism,  it  being  quite  possible  that  the 
writer  should  be  a  skilful  surgeon  without  being  perfectly 
familiar  with  the  locks  of  lithotrites,  —  just  as  a  skilful 
navigator  may  not  have  investigated  the  construction  of 
the  chronometer  he  uses. 

Several  of  the  critical  remarks  of  your  able  editorial  writer 
are  well  founded.  He  rightly  says  that  the  evacuating  pro- 
cess, though  not  more  efficient,  is  drier  and  neater  if  all  the 
water  is  kept  inside  the  aspirator  and  all  the  air  outside  of  it ; 
which  implies  that  there  should  be  good  joints  and  no  leakage, 
with  stopcocks  at  all  the  orifices,  one  of  them  being  at  the 
highest  point  to  let  air  out  easily.  I  would  add,  however, 
that  it  is  important  not  to  lose  sight  of  convenience  in  other 
respects. 

The  progress  of  the  new  lithotrity  was  most  liberally  en- 
couraged, at  an  early  period,  by  New  York  surgeons.  The 
attention  now  directed  to  some  of  the  minor  details  con- 
nected with  the  instruments  is  rapidly  contributing  to  their 
perfection. 

Almost  the  only  objection  I  have  known  made  to  the  new 
method,  either  here  or  abroad,  has  been  directed  to  the  size 
of  the  instruments  I  generally  use,  which  at  first  impressed 
persons  accustomed  to  the  use  of  Clover's  aspirator  and  the 


260  LITHOLAPAXY. 

English  lithotrite  as  "  clumsy  ''  or  "  unwieldy."  Large-sized 
catheters  are  absolutely  indispensable,  and  are  now  so  recog 
nized.  With  regard  to  the  size  of  the  lithotrite,  it  is  to  a 
certain  extent  a  matter  of  taste.  My  own  instrument,  with  a 
wrist-lock,  ball-handle,  and  non-impacting  blades,  is  not  neces- 
sarily larger  than  others.  It  can  be  had  from  Tiemann  and 
Co.  of  any  size  the  operator  may  prefer.  I  think,  however^ 
that  large  and  hard  stones  will  be  found  to  require  a  more 
powerful  instrument  than  those  hitherto  in  use.  In  fact,  it 
is  very  possible  that  a  calculus  should  break  a  lithotrite.  This 
accident  happened  from  time  to  time  in  the  practice  of  the  old 
lithotrity,  and  we  are  now  dealing  with  larger  and  harder 
stones.  That  is  one  reason  for  avoiding  a  slender  construc- 
tion, especially  of  the  blades  ;  but  my  chief  reason  for  using 
a  large  lithotrite  is  the  convenient  command  it  gives  of  the 
stone.  Having  learned  how  easy,  as  well  as  safe,  with  proper 
care  and  skill,  is  the  introduction  of  large  instruments,  I  pre- 
fer to  use  a  powerful  lithotrite  to  crush  even  a  moderate-sized 
calculus,  provided  the  blades  are  so  constructed  as  not  to  be- 
come impacted.  With  a  small  stone  or  fragment  the  choice 
of  a  lithotrite  is  wholly  unimportant ;  while  a  bladder  or 
urethra,  if  exceptional  in  any  way,  may  require  an  excep- 
tional instrument.  But  I  do  not  see  why  some  operators 
still  enjoin  the  use  in  all  cases  of  the  smallest  or  lightest 
lithotrite  that  can  possibly  be  made  to  crush  the  calculus. 

Henry  J.  Bigelow* 
Boston,  Mass. 


LITHOLAPAXY.  261 


LITHOLAPAXY.i 

In  a  paper  upon  litholapaxy  published  last  year,  I  reported 
twelve  cases  with  one  death.  Below  is  a  record  of  nine  cases 
upon  which  I  have  since  operated  successfully,  under  ether  as 
before  :  — 

Case  XIII. —  March  9,  1878.  Age,  thirty-three.  Stone  weigh- 
ing two  hundred  and  forty  grains.  Time,  sixty-eight  minutes. 
Rapid  recovery.  The  patient,  for  many  months  very  ill,  was  at 
once  relieved. 

Case  XIV. —  Dec.  20,  1878.  Age,  sixty-nine.  Stone  measur- 
ing eleven  centimetres  by  fifteen.  Time,  forty-five  minutes.  Usual 
recovery. 

Case  XV. — Jan.  24,  1879.  Age,  sixtj'-seven.  Stone  weighing 
two  hundred  and  sixty  grains.  Time,  forty-six  minutes.  Usual 
recovery. 

Case  XVI.— Feb.  10,  1879.  Age,  fifty.  Three  hundred  and 
two  grains  of  hard  oxalate  stone.  Time,  one  hour  and  twenty-one 
minutes.  Usual  recovery.  This  was  the  largest  hard  stone  yet 
treated  by  immediate  evacuation. 

Case  XVII.  —  April  7,  1879.  Age,  fifty-four.  One  hundred 
and  eight  grains  of  hard  oxalate  stone.  Time,  thirty-five  minutes. 
Usual  recovery. 

Case  XVIII.  — April  26,  1879.  Age,  forty.  Stone  of  the  size 
of  a  marble.  Time,  twenty-seven  minutes.  Usual  recovery.  Only 
worthy  of  record  as  immediately  relieved  from  great  irritation  of 
four  years'  duration. 

Case  XIX. —  June  4,  1879.  Age,  sixtj^-five.  Stone  weighing 
two  hundred  and  forty-two  grains,  mixed  lithic  and  phosphatic. 
Time,  forty-six  minutes.     Usual  recovery. 

Case  XX. —  Small  stone.  Usual  recover}'.  The  only  case 
where  I  was  unable  to  pass  a  straight  tube,  from  obstruction  at 
the  internal  meatus. 

1  The  Boston  Medical  and  Surgical  Journal,  Oct.  16,  1879. 


262  LITHOLAPAXY. 

Case  XXI. —  July  21,  1879.  Age,  twentj^-one.  A  large  stone 
of  seven  hundred  and  twenty  grains.  Measurement,  two  and  one 
fourth  inches.  Time,  one  hour  and  seventeen  minutes.  Usual 
recovery. 

It  is  unnecessary  to  say  that  these  operations  were  done 
deliberately,  —  neither  the  anaesthesia,  the  crushing,  nor  the 
evacuation  requiring  haste.  I  have  hitherto  reported  the 
time  of  my  operations  to  illustrate  and  impress  this  fact, 
which  was  a  new  one.  Surgeons  familiar  with  the  use  of 
ether  do  not  hesitate  to  continue  anaesthesia  almost  indefi- 
nitely if  there  is  anything  to  be  gained  by  it.  Nor  is  the 
bladder  itself  affected  unfavorably  by  a  protracted  operation. 
Indeed,  "  rapid  lithotrity  "  —  a  name  intended  to  designate  a 
long  sitting  for  the  purpose  of  removing  the  whole  stone 
through  a  large  tube  —  calls  for  greater  deliberation  and  care 
than  the  old  dilatory  lithotrity  by  repeated  two-minute  sit- 
tings, with  an  interval  of  days  between  them.  It  is  rapid 
only  as  a  whole,  and  when  compared  with  the  old  operation. 

The  details  of  a  case  may  further  illustrate  this,  —  for  exam- 
ple, the  last  here  recorded,  where  seven  hundred  and  twenty 
grains  were  removed  in  one  hour  and  seventeen  minutes,  the 
stone  being  the  largest  but  one  as  yet  subjected  to  operation 
by  the  new  method.  Here  four  crushings  occupied  twelve, 
six,  six,  and  four  minutes ;  and  five  washings,  six,  four, 
twelve,  and  seven  minutes,  respectively,  vvith  intervals  added. 
But  a  very  large  part  of  this  stone  was  removed  in  ten  min- 
utes by  the  first  two  short  washings ;  the  remainder  of  the 
time  was  for  the  most  part  devoted  to  a  leisurely  and  careful 
search  for  residuary  fragments.  As  performed  here  now,  the 
operation  consists  of  litholapaxy,  followed  by  thorough  sound- 
ing with  a  tube.  It  may  be  made  shorter  by  not  completing 
it,  —  by  postponing  the  final  exploration.  In  other  words, 
surgeons  may  prefer  to  leave  the  last  fragments  for  a  second 
operation.     This  has  been  proposed  by  one  of  the  strongest 


LITHOLAPAXY.  263 

advocates  of  haste,  which  is  a  habit  connected  with  the  two- 
minute  sitting,  insisted  on  when  it  was  erroneously  supposed 
that  damage  to  the  bladder  was  in  proportion  to  the  time 
occupied  by  instrumentation.  The  tradition  has  so  strong 
a  hold  on  surgeons  that  cases  of  rapid  lithotrity  are  still 
reported,  in  which  the  operator  seems  to  have  been  under 
pressure  of  some  sort  to  finish  the  sitting  quickly,  at  all 
hazards,  as  if  it  were  essential  to  do  so  ;  and  yet  the  per- 
formance of  lithotrity  against  time  will  probably  be  soon  as 
obsolete  as  is  now  haste  in  other  operations  under  ether 
anaesthesia. 


264  LITHOLAPAXY. 

LITHOLAPAXY ; 

OR, 

LITHOTRITY   WITH   IMMEDIATE   EVACUATION.i 

The  communication  I  have  the  honor  to  make  relates  to  a 
modification  of  the  operation  of  Lithotrity.  It  is  a  proposition 
to  supersede  frequent  sittings,  as  nearly  as  may  be,  by  a  single 
sitting  of  sufficient  length  to  enable  the  surgeon  to  crush  the 
calculus  completely  and  remove  all  the  fragments. 

In  the  opposite  practice,  which  has  hitherto  prevailed,  the 
calculus,  unless  it  were  very  small,  was  broken,  a  little  at  a 
time,  at  intervals  of  a  few  days,  and  the  pieces  were  left  in 
the  bladder.  For  this  course  there  was  a  plausible  reason. 
The  inflammation  that  sometimes  followed  the  operation  was 
naturally  attributed  to  the  instrument  used  in  crushing  the 
stone ;  and  the  shorter  the  operation  the  less,  it  was  supposed, 
would  the  irritation  probably  be.  Under  this  impression, 
skilful  operators,  ever  since  Civiale,  have  reduced  the  length 
of  the  sitting  to  a  few  minutes,  —  hesitating  to  continue 
manipulation  even  with  instruments  of  polished  metal.  They 
had  no  hesitation,  however,  in  leaving  the  mucous  membrane 
exposed  for  weeks  to  sharp,  ragged  edges  of  broken  stone,  — 
the  fragments  in  the  bladder  remaining  where  they  were, 
because  there  was  no  instrument  for  removing  them. 

The  removal  of  mere  sand  and  minute  fragments  by  suction 
through  the  uretlira  is  old,  and  dates  from  Crampton,  who 
records  two  drachms  of  sand  drawn  out  at  once,  —  of  which, 
I  believe,  no  larger  quantity  has  since  been  so  removed  at 
one  sitting.  This  sort  of  detritus  also  escapes  of  itself,  by 
the  urethra,  without  inconvenience.     But  fragments  large  or 

1  Transactions  of  the  Clinical  Society  of  London,  vol.  xii.,  1879.  Read 
Oct.  25,  1878. 


LITHOLAPAXY.  265 

abundant  enough  to  be  important  factors  in  producing  irrita- 
tion have  never  till  now  been  got  rid  of.  One  insuperable 
obstacle  has  always  been  the  small  size  of  the  evacuating 
catheter.  The  aspirator  of  Clover,  for  example,  is  inefficient, 
partly  because  the  catheter,  having  the  small  calibre  of  21 
French,  allows  the  passage  only  of  sand  and  a  few  minute 
fragments. 

So  long  as  the  two  sources  of  injury,  the  crushing  and  the 
fragments  left  by  it,  were  thus  inseparable,  their  effects  could 
not  be  distinguished,  and  there  was  a  strong  feeling  against 
any  protracted  manipulation  of  the  stone.  To  withdraw  the 
offending  fragments  was  the  only  possible  way  to  discover 
what  was  the  effect  of  the  crushing  itself,  and  how  far  it  might 
be  prolonged. 

It  has  happened  that  I  have  always  etherized  patients  for 
lithotrity ;  and  as  there  was  no  pain  in  the  operation,  I  not 
infrequently  protracted  the  sittings  to  ten  or  fifteen  minutes. 
The  need  I  felt  was  not  of  more  crushing,  —  for  I  was  already 
doing  as  much  of  this  as  seemed  advantageous,  —  but  rather  of 
some  w^ay  to  get  rid  of  what  was  already  crushed.  The  singu- 
lar insensibility  sometimes  shown  by  the  bladder  not  merely 
to  the  presence  of  calculi  to  which  it  had  become  accustomed, 
but  also  to  lithotrity,  and  by  the  urethra  to  divulsion,  was  too 
striking  to  be  overlooked,  and  made  it  probable  that  the 
mucous  membrane  would  tolerate  a  good  deal  of  interference 
if  it  were  decisively  terminated,  and  irritation  were  not  kept 
up  by  the  unwonted  presence  of  sharp  fragments  left  in  the 
bladder.  When  Otis  announced  the  great  capacity  of  the 
urethra,  now  familiar  through  Van  Buren's  steel  sounds,  it 
became  obvious  that  large  fragments  of  stone  might  be  re- 
moved. I  therefore  had  some  tubes  of  corresponding  size 
made,  and  soon  after  adopted  the  evacuating  catheters  and 
the  aspirator  I  now  use,  by  which  the  bladder  can  be  rapidly 
emptied  of  any  common  amount  of  debris.     I  experimented 


266  LITHOLAPAXY. 

with  caution,  in  view  of  the  overwhelming  weight  of  tradi- 
tional and  current  testimony.  A  gentleman,  then  lately  from 
abroad,  who  had  had  unusual  opportunities  for  observation  of 
lithotrity,  told  me,  after  seeing  one  of  my  earlier  operations, 
that  the  mechanical  procedure  might  be  good,  but  that  the 
patient  would  die.  Yet  he  recovered.  This  and  other  simi- 
lar cases,  then  first  treated  by  the  aid  of  large  evacuating 
catheters  and  an  efficient  aspirator,  showed  a  tolerance  on 
the  part  of  the  bladder  to  the  use  of  instruments,  which  had 
till  then  been  unsuspected. 

These  considerations  involve  this  new  principle  in  litho- 
trity, that  it  is  better  to  remove  all  the  fragments  immediately, 
because  the  bladder  does  tolerate  a  good  deal  of  mechanical 
disturbance  with  the  lithotrite  and  aspirator,  if  only  that  be 
all,  — •  with  the  obvious  rule  that  we  may  substitute,  for  the 
traditional  few  minutes  of  a  sitting,  time  enough  to  remove 
the  whole  stone. 

Experience  has  confirmed  both  the  principle  and  the  rule ; 
and  although  it  is  impossible  now  to  prescribe  the  limits  of 
the  operation,  I  have  frequently  continued  it  for  an  hour 
with  successful  results,  and  have  known  eighteen  hundred 
grains  to  be  removed  in  three  sittings,  of  about  three 
hours  each,  under  ether,  —  the  result  being  almost  imme- 
diate relief. 

The  long  sittings  of  the  new  method  suggest  other  precau- 
tions besides  those  usual  in  common  lithotrity.  Instead  of 
withdrawing  the  lithotrite  frequently  to  clean  it,  I  have 
devised  blades  that  cannot  become  impacted  with  detritus. 
The  old  fenestrated  instruments  do  not  clog, — and  in  tliat 
respect  work  well,  especially  as  the  coarse  gravel  that  passes 
the  fenestra  of  the  female  blade  will  also  pass  through  the 
large  catheters.  Dr.  Van  Buren  and  Dr.  Keyes  have  used 
the  fenestrated  lithotrite  successfully  in  the  new  operation. 
But  this  allows  sharp  fragments  to  be  pressed  through  the 


LITHOLAPAXY. 


267 


instrument  against  the  floor  of  the  bladder  ;  and  I  doubt  if 
this  is  harmless.  The  sides  also  of  a  fenes- 
trated blade  are  weakened,  if  made  low  enough 
to  receive  fragments  readily.  Therefore,  while 
this  mode  of  construction  may  be  serviceable 
for  small  stones  or  fragments,  I  usually  prefer 
a  solid  female  blade  to  protect  the  floor  of  the 
bladder,  relying  on  a  self-cleaning  male  blade 
to  prevent  impaction.  I  like  also  a  large  litho- 
trite  to  crush  common  stones  as  well  as  large 
ones  ;  but  if  the  operator  prefers,  he  can  use 
different  lithotrites  for  different  stones. 

In  a  long  operation,  when  the  attention  gets 
wearied,  the  lithotrite  is  liable  to  catch  the  wall 
of  the  bladder.  When  the  operation  exceeds  a 
few  minutes,  the  average  surgeon  cannot  be  re- 
lied on  always  to  turn  up  the  instrument  in  the 
centre  of  the  bladder  before  crushing ;  and  the 
forceps-like  blades  of  the  best  common  litho- 
trites are  well  arranged  to  do  injury.  I  find 
great  advantage,  and  no  disadvantage,  in  a  long 
and  blunted,  as  well  as  wide,  female  blade.  This 
keeps  the  walls  of  the  bladder  back  while  the 
male  blade  is  securing  the  fragments,  either 
when  they  fall  into  a  depression  made  in  the 
floor  by  the  female  blade,  or  when  the  litho- 
trite, previously  opened,  is  turned  to  one  side 
and  closed  along  the  floor. 

In  crushing,  the  easiest  movement,  and  the 
one  that  recurs  most  frequently,  is  the  rotation 
of  the  right  wrist  in  screwing  down  the  male 
blade.     The  lock  of  my  lithotrite   is    shut   and    opened   by 

^  Author's  lithotrite.     a,  Spherical   handle  substituted  for  a  wheel; 
6,  cylinder  which  operates  upon  the  lock  c. 


Fig.  1.1 


268  LITHOLAPAXY. 

this  same  movement,  and  can  be  applied  to  any  lithotrite. 
The  same  movement  that  locks  it  begins  the  crushing,  and 
the  reverse  movement  unlocks  it, — the  requisite  force  be- 
ing applied  by  a  ball,  in  preference  to  the  wheel  commonly 
used.^ 

The  Aspirating-Siphon  is  an  elastic  tube,  having  at  one  end 
an  evacuating  catheter,  at  the  other  an  elastic  oval-shaped 
bottle,  terminated  below  by  a  glass  receptacle  and  supported 
on  a  stand.  The  bottle  itself  is  strong,  and  when  compressed 
dilates  with  force.  Fragments  enter  at  the  top  and  fall  to  the 
bottom,  into  the  glass  receiver,  where  they  remain.  They  can- 
not return  from  the  bottle  to  the  bladder,  as  happens  when, 
to  reach  the  trap,  they  must  pass  the  mouth  of  the  evacuating 
tube.  But  if  they  could,  no  harm  would  ensue, —  evacuation 
with  large  catheters  being  so  rapid  that  a  fragment  or  two 
returned  to  the  bladder  is  very  soon  brought  back  again. 
When  the  fragments  once  enter  the  catheter,  they  pass  so 
quickly  to  the  bottle  as  to  make  it  possible,  without  retarding 
them,  to  interpose  between  the  catheter  and  bottle  several 
inches  of  elastic  tube  to  relieve  the  bladder  from  the  vibration 
of  the  aspirator,  and  to  make  the  catheter  independent  of  any 
motion  of  the  other  jjart  of  the  apparatus.  If  the  surgeon 
guides  the  catheter  with  his  left  hand  supported  on  the  pa- 
tient's thigh,  the  elastic  tube  allows  a  delicacy  of  manipulation 
which  is  hardly  possible  when  the  bottle  is  rigidly  attached  to 
the  catheter,  especially  if  it  surmounts  it. 

1  After  careful  experiment  as  to  the  easiest  movement  of  the  hand  and 
arm  in  crushing,  whicli  is  undoubtedly  the  rotation  here  spoken  of,  I 
adapted  the  lock  to  it.  It  requires  no  displacement  of  the  fingers.  If 
any  easier  movement  be  discovered,  there  will  be  an  advantage  in  adapt- 
ing a  lock  to  that.  I  have  heard,  in  apology  for  the  traditional  wheel 
as  a  handle,  that  the  awkward  hold  it  gives  the  hand  prevents  the  appli- 
cation of  sufficient  force  to  break  the  blades ;  but  the  blades,  without 
being  too  large  to  pass  easily  through  the  urethra,  can  be  made  strong 
enough  to  resist  the  better  grasp  allowed  by  a  ball. 


LITHOLAPAXY. 


269 


The  calibre  of  an  evacuating  catheter  determines  the  size 
of  the  fragments  that  pass  it.     Beginning  with  27  French,  I 


Fig.  2.1 

gradually  increased  the  size  to  31, ^employing,  as  a  rule,  a 
calibre  of  30.  Smaller  tubes  transmit  smaller  and  fewer  frag- 
ments ;  I  therefore  prefer  at  least  30,  when  it  can  be  used.     If 

1  Aspii-ating-Siphon  in  a  stand  which  ha.s  a  ball  and  socket  joint  to 
allow  the  bottle  to  stand  in  an  easy  position.  The  glass  trap  is  sur- 
mounted by  an  oval  bottle  and  curved  tube  of  rubber,  terminated  by  a 
stop-cock.  When  the  latter  is  coupled  with  the  stop-cock  upon  the  evac- 
uating catheter,  the  two  are  kept  open  by  a  hinged  clip,  seen  in  the 
drawing. 


270 


LITHOLAPAXY. 


the  surgeon  prefers  28  or  29,  he  can  further  crush  the  frag- 
ments that  will  not  pass  through  these.  The  catheter  should 
have  its  lower  orifice  of  full  calibre,  with  a  prolonged  blunt 
extremity  or  lip  to  facilitate  its  passage  into  the  bladder,  and 
to  keep  the  vesical  walls  away  from  the  opening. 


Fig.  3.1 

I  use  a  straight  tube.  It  is  introduced  more  readily  than  a 
curved  one,  and  shows  better  how  it  lies  in  the  bladder.  The 
fragments,  under  aspiration,  are  so  constantly  moving  that  a 
curved  instrument  is  not  needed  to  find  them,  as  in  sounding ; 
on  the  contrary,  they  find  the  catheter.  If,  however,  a  bent 
tube  be  preferred,  the  curve  should  be  short,  the  hole  close  to 
the  end,  and  of  full  dimensions. 

To  introduce  a  large  tube,  the  urethra  is  copiously  oiled 
with  a  syringe,  and  its  calibre  ascertained  with  a  steel  sound. 
The  meatus,  the  narrowest  part,  may  be  snipped  with  scissors, 
if  necessary,  or  a  stricture  be  enlarged  by  divulsion ;  but  a 
calibre  of  30  will  usually  enter  the  normal  passage.  Whether 
straight  or  curved,  the  evacuating  catheter  is  passed  perpen- 
dicularly as  far  as  the  rectum.  The  straight  catheter  is  then 
laid  horizontally,  —  a  movement  that  tilts  up  the  end  to  the 


1  Extremities  of  straight  and  curved  tubes,  of  the  sizes  27  and  31. 


LITHOLAPAXY.  271 

orifice  in  the  triangular  ligament.  This  entered,  the  instru- 
ment is,  by  a  screw-like  motion  in  the  axis  of  the  body, 
passed  through  the  prostate,  the  eccentric  extremity  readily 
finding  its  way.  In  one  form  of  enlarged  prostate  a  further 
elevation  of  the  point  of  the  catheter  may  be  required  to  find 
the  aperture  in  the  triangular  ligament.  But  the  common 
difiiculty  of  passing  an  instrument  of  any  sort  results  from  a 
premature  depression  of  the  handle,  which  raises  the  other 
end  above  the  orifice.  This  observation  is  not  new,  but 
requires  to  be  emphasized  in  connection  with  large-sized  in- 
struments. It  is  also  useful  to  press  the  bent  part  of  a 
curved  instrument  in  the  direction  of  the  axis  of  the  body, 
with  the  left  hand  on  the  peringeum;  It  need  not  be  said 
that  all  the  movements  are  gentle  and  deliberate.  Rapid 
lithotrity  should  be  done  slowly. 

The  stone  is  crushed  as  usual,  except  that  a  non-impacting 
lithotrite  may  be  kept  in  the  bladder  to  advantage  until  the 
fragments  are  lost  in  the  detritus.  When  the  latter  is  re- 
moved, the  crushing  is  repeated.  Detritus  is  withdrawn 
better  by  a  catheter  than  by  an  impacted  lithotrite,  and  a  few 
alternate  operations  of  crushing  and  aspiration  suffice  to  evac- 
uate a  stone  of  considerable  size. 

As  preliminary  to  aspiration,  the  evacuating  catheter  is 
introduced  and  the  bladder  emptied,  leakage  being  prevented 
by  a  band  tied  round  the  penis.  The  bottle  is  filled  by  letting 
it  dilate  while  the  elastic  tube  is  immersed  in  water;  and,  the 
stop-cock  being  then  closed,  it  is  placed  in  its  stand.  To  expel 
the  air  from  the  evacuating  catheter,  this  may  be  also  filled 
by  means  of  a  syringe,  and  its  stop-cock  also  closed.  It  re- 
mains to  couple  the  full  bottle  with  the  catheter  in  the  empty 
bladder.     The  apparatus  is  now  ready. 

An  aspiration  that  withdraws  two  or  three  ounces  of  water 
about  twice  in  three  seconds  brings  a  continuous  shower  of 
detritus  into  the  glass  cylinder.     If  the  bottle  expands  reluc- 


272  LITHOLAPAXY. 

tantly,  a  fragment  is  lodged  in  the  catheter,  and  a  sharp 
compression  of  the  bottle  will  probably  eject  it ;  but  if  not,  it 
may  be  pushed  back  with  a  rod.  Several  successive  jerks, 
similar  to  the  bite  of  a  fish,  signify  a  valve-like  stoppage  of 
the  opening  in  the  catheter  by  the  elastic  walls  of  the  bladder. 
The  latter  is  then  too  flaccid,  and  needs  a  few  ounces  more  of 
water  from  the  bottle  to  distend  it;  after  which  the  stop-cocks 
are  shut,  and  the  bottle  is  replenished.  This  common  sign  is 
generally  a  valuable  one,  because  it  indicates  a  good-sized 
bladder ;  but  it  sometimes  happens  when  the  opening  of  the 
catheter  is  turned  sideways,  and  does  not  occur  with  a  curved 
catheter. 

The  operator  sits  on  the  patient's  right.  Evacuation  is 
very  rapid  when  the  catheter  is  held  properly;  and  the  best 
place  for  the  end  of  the  instrument  is  ascertained  by  trying. 
It  is  a  little  curious  that  a  continued  shower  of  detritus  is 
sometimes  brought  into  the  trap  by  changing  the  direction  or 
elevation  of  the  catheter  only  a  quarter  of  an  inch.  Any  good 
position  should  be  maintained  accurately.  A  good  place  for 
aspiration  is  just  off  the  floor  of  the  bladder ;  higher,  when 
the  first  fragments  are  crowding  into  the  tube  and  need  to 
be  received  in  single  file ;  and  lower,  in  a  depression  of  the 
floor,  when  the  debris  require  to  be  assembled.  The  last 
fragment,  if  small  enough,  is  sure  to  enter  the  catheter  after 
a  while.  By  a  few  minutes'  aspiration  in  a  tumbler  covered 
with  a  napkin,  I  can  always  isolate,  from  a  mass  of  broken 
coal,  the  only  bits  too  large  to  enter  the  catheter.  As  the 
sand  is  cleared  away,  fragments  announce  their  presence 
by  clicking  against  the  tube ;  a  long,  full-sized  one  may  be 
arrested  half-a-dozen  times  before  its  final  withdrawal  and 
appearance  in  the  trap.  When  tlie  clicking  has  ceased  for  a 
minute  or  two,  the  bladder  is  practically  clear;  and  there 
remains  only  a  final  exploration  with  a  tube  or  lithotrite  at  a 
convenient  time. 


LITHOLAPAXY.  273 

A  little  air,  mostly  from  the  evacuating  catheter,  may  get 
into  the  bladder  during  the  operation,  —  but  does  no  harm,  if 
it  does  not  over-distend  a  small  bladder.  The  air  is  readily 
discharged  with  the  urine ;  but  it  is  well  from  time  to  time  to 
open  the  evacuating  catheter  and  expel  it,  by  compressing  the 
bladder  above  the  pubes. 

The  pulse  and  temperature,  usually  higher  the  day  after  the 
operation,  soon  subside,  the  general  treatment  of  symptoms 
being  much  the  same  as  after  lithotrity. 

By  this  method,  which  I  have  called  Litholapaxy,  its  pecu- 
liar feature  being  evacuation,  tenacious  mucus  with  phosphatic 
deposit,  as  well  as  nuclei  and  certain  foreign  bodies,  can  be  bet- 
ter removed  than  in  any  other  way. 


274  LITHOLAPAXY. 

LITHOLAPAXY. 

AN   IMPEOVED   EVACUATOR.^ 

The  operation  for  the  complete  removal  of  a  stone  at  one 
sitting  has  been  as  successful  as  its  most  sanguine  advo- 
cates could  have  hoped.  Several  years  may  still  be  needed 
to  determine  precisely  its  relative  value ;  but  in  the  mean 
time  it  has  been  abundantly  proved  that  the  bladder  toler- 
ates long  operations,  —  provided  the  fragments  of  the  stone, 
which  are  the  principal  cause  of  inflammation,  be  removed,  — 
and  that  fragments  need  no  longer  be  a  source  of  inflamma- 
tion. Although  several  cases  of  litholapaxy  have  terminated 
fatally,  the  cause  of  death  was  not  the  usual  one  after  such 
operations ;  it  was  not  an  inflammation  of  obscure  origin,  con- 
nected with  previous  disease  of  the  bladder  or  of  the  kidneys. 
The  few  deaths  that  have  occurred  were  due  to  mechanical 
injury,  which  with  greater  experience  in  operations  of  this 
kind  will  doubtless  in  the  future  be  avoided. 

It  has  been  remarked  by  more  than  one  writer  that  the  new 
lithotrity  requires  even  more  care  than  was  necessary  in  the 
old  method  by  short  sittings.  This  is  true.  Each  repeated 
act  of  crushing  or  of  evacuation  is  obviously  liable  to  its  own 
casualties ;  and  we  must  add  to  this  liability  any  that  may 
arise  from  the  gradual  abatement  of  the  operator's  vigilance. 
It  was  once  an  object,  in  persuading  surgeons  to  forego  their 
traditional  prejudices,  to  show  that  the  new  operation  was 
safer  than  they  supposed ;  but  this  being  now  generally  con- 
ceded, it  is  at  present  important  to  insist  that  it  should  be 
attempted  only  by  practised  lithotritists,  or  by  a  beginner  only 
after  familiar  practice  upon  the  cadaver.     I  know  no  other 

*  Boston  Medical  and  Surgical  Journal,  Jan.  8,  1880. 


LITHOLAPAXY.  275 

surgical  operation  in  which  a  little  want  of  skill  or  of  care 
is  so  insidiously  liable  to  fatal  accident.  The  skill  here  is  of 
a  particular  kind  ;  and  though  a  surgeon  may  use  a  knife  well, 
it  does  not  follow  that  he  also  uses  a  lithotrite  well.  Before 
considering  this  instrument,  however,  let  us  examine  the 
evacuator,  or  "  rubber  bulb." 

It  was  an  alteration  of  the  evacuator  that  made  lithola- 
paxy  possible,  and  led  to  the  discovery  of  the  tolerance  of  the 
bladder.  This  was  the  enlargement  of  its  tubes  from  the  size 
of  the  common  catheter  to  the  largest  the  urethra  will  admit 
without  injury.  In  evacuating  a  small  stone  the  smaller  of 
the  new  large  tubes  (26  or  27  French)  works  well  enough ; 
but  in  order  to  evacuate  a  considerable  stone  with  comfort 
either  to  the  surgeon  oi"  to  the  patient,  we  need  a  tube  of 
from  28  to  31 ;  and  for  its  introduction  it  is  often  well  to  en- 
large the  meatus,  which  is  the  narrowest  part  of  the  uretlira. 
I  cannot  but  think  that  the  preference  of  some  operators  for 
the  curved  tube  I  at  first  employed  is  connected  with  their 
previous  familiarity  with  curved  catheters ;  and  yet  when 
a  curved  evacuating  tube  is  in  position  its  entire  curve  is 
in  the  bladder,  and  in  the  manipulation  of  the  instrument 
there  exists  the  disadvantage  of  not  knowing,  as  readily  as 
with  a  straight  tube,  where  its  point  lies.  The  orifice  in 
either  case  is  on  the  side  of  the  extremity,  and  there  is  a 
quarter  of  an  inch,  more  or  less,  of  tapering  solid  metal  be- 
yond it,  necessary  to  make  its  introduction  easy  and  to  keep 
the  bladder  from  obstructing  it. 

The  large  evacuating-tube  being  the  essential  instrument 
in  the  new  operation,  a  vacuum  produced  by  almost  any  ap- 
paratus will  draw  fragments  through  it.  Certain  principles, 
however,  observed  in  their  construction  will  make  them  more 
convenient  and  efficient. 

An  apparatus  I  early  employed  consisted  of  a  stiff  bulb  and 
Clover's  trap,  attached  to  the  large  catheter  by  a  short  elastic 


276  LITHOLAPAXY. 

tube.  The  combination  was  a  good  one ;  for  the  elastic  tube 
allowed  the  bulb,  when  in  use,  to  be  bent  down  to  the  level  of 
the  bladder.  The  bulb  could  thus  be  laid  on  its  side,  and  by 
further  depression  reversed  ;  which  brought  the  catheter  tube 
to  the  top.  It  then  remained  only  to  construct  a  glass  trap 
at  its  lowest  point,  so  that  the  fragments  should  be  left  where 
they  fell.  This  arrangement,  placed  in  a  stand,  is  practically 
the  evacuator  I  still  use. 

A  strong  rubber  bulb  is  an  indispensable  substitute  for  the 
former  slender  one. 

In  the  glass  trap  at  the  bottom  of  the  instrument  the  frag- 
ments ai'e  kept  out  of  the  current  at  a  point  distant  from  the 
catheter.  After  entering  at  the  top  of  the  bulb,  they  settle  at 
once  to  the  bottom  and  remain  there  undisturbed. 

If  fragments  are  drawn  through  the  tube  with  the  force  and 
rapidity  that  are  given  to  the  current  by  a  strong  rubber 
bulb,  a  few  inches  added  to  the  length  of  the  route  are  of 
no  consequence.  A  short  and  curved  elastic  tube  five  inches 
long,  —  but  which  I  have  varied  from  two  inches  to  two  feet,  — 
between  the  bulb  and  the  evacuating  tube,  makes  it  possible 
to  move  one  without  the  other.  It  relieves  the  surgeon  and 
protects  the  patient.  The  surgeon  can  explore  the  bladder  in 
search  of  fragments  without  having  to  move  the  bulb,  which 
weighs  a  pound  or  two ;  while  the  jar  of  pumping  does  not 
reach  the  bladder.  The  discomfort  to  the  unetherized  patient 
resulting  from  this  jar  is  a  serious  objection  to  the  rigid  attach- 
ment of  the  bulb  of  water  to  the  tube.  The  bulb  should  have 
a  support  of  its  own,  placed  upon  the  table  or  bed  between  the 
patient's  legs,  which  may  be  separated  a  little  as  in  the  case 
of  the  introduction  of  a  catheter  or  a  lithotrite.  The  sur- 
geon's hand,  instead  of  supporting  the  evacuator,  is  then  sup- 
ported by  it. 

The  bulb,  when  thus  near  the  level  of  the  bladder,  acts  as 
a  siphon.     This  is  desirable.     By  experiment  it  will  be  found 


LITHOLAPAXY. 


277 


278  LITHOLAPAXY. 

that  the  difficulty  of  suction  increases  as  the  bulb  is  held 
higher  than  the  evacuating-tube ;  it  is  very  marked  in  Clover's 
instrument.  There  is  great  advantage  in  keeping  the  bulb 
low,  near  the  level  of  the  bladder. 

The  evacuator  thus  described  works  very  well.  I  have  used 
it  in  most  of  the  operations  I  have  performed.  Its  imperfec- 
tions are  that  if  by  accident  a  little  air  gets  inside,  the  bulb  has 
to  be  uncoupled  to  get  rid  of  it,  and  a  few  drops  of  water  may 
escape  and  wet  the  bed.  By  a  simple  expedient  I  have  reme- 
died these  inconveniences.  In  the  instrument  I  here  show 
(Fig.  1)  the  air  can  be  removed,  or  water  withdrawn  from 
the  bulb,  or  added  to  it,  without  a  drop  being  spilled.  Indeed, 
the  operation  would  be  absolutely  dry  did  not  a  sensitive  blad- 
der occasionally  contract  and  squeeze  out  a  little  water  by  the 
side  of  the  lithotrite  or  catheter,  in  spite  of  the  elastic  band  I 
usually  tie  around  the  penis  to  prevent  it.  When  this  hap- 
pens, it  is  perhaps  best  not  to  try  to  stop  it. 

In  this  instrument  the  large  evacuating  tube  at  the  top  of 
the  bulb  extends  an  inch  or  more  downward  into  its  cavity. 
A  space  is  thus  formed  where  any  accidental  air  collects,  but 
cannot  pass  to  the  bladder.  This  space  is  emptied  at  will 
through  an  elastic  tube  or  hose,  a  little  more  than  a  quar- 
ter of  an  inch  in  diameter,  placed  by  the  side  of  the  first. 
The  arrangement  is  a  very  simple  one.  Through  this  small 
hose,  which  can  be  attached  and  detached  in  a  moment,  the 
turbid  contents  of  the  bulb  may  be  replaced  by  clear  water 
without  unfastening  it  from  the  catheter  ;  or  the  contents  of 
a  tumblerful  of  water  can  be  transferred  to  the  bladder  and 
back  again,  absolutely  without  loss,  and  with  the  elimination 
of  all  the  air.  With  one  end  of  the  apparatus  in  the  bladder 
and  the  other  in  a  tumbler  of  water,  the  operator,  even  while  he 
is  evacuating  the  fragments,  can  vary  the  volume  of  water  at 
will  and  put  it  where  he  pleases.  The  catheter  and  the  elastic 
tubes,  large  and  small,  are  each  provided  with  a  stop-cock. 


LITHOLAPAXY.  279 

If  before  using  the  lithotrite  the  surgeon  desires  to  add  or 
withdraw  water  from  the  bladder,  this  may  be  done  through  a 
common-sized  catheter  coupled  with  the  bulb,  —  thus  obviat- 
ing the  necessity  for  a  syringe,  and  rendering  this  part  of  the 
operation  as  dry  as  the  rest. 

Instead  of  the  metal  ball-and-socket  joint  in  the  stand  of 
my  former  instrument,  I  have  substituted  another,  of  which 
a  strong  glass  trap  forms  the  ball.  This  is  supported  in  a 
metal  socket,  which  allows  all  necessary  motion  or,  if  it  is 
desirable,  fixes  the  trap  upon  the  flat  disk. 

The  operation  is  as  follows.  The  urine  is  drawn  through  a 
small  catheter,  and  replaced  by  water  from  the  bulb.  The 
lithotrite  is  then  introduced,  and  the  stone  is  crushed.  A 
large  tube  is  next  passed  into  the  bladder  to  evacuate  the 
fragments.  Before  the  tube  is  introduced,  its  stop-cock  must 
be  closed.  If  during  the  pumping  the  bladder  indicates,  by 
repeatedly  stopping  the  tube,  that  its  parietes  are  hanging 
loose  and  acting  as  a  valve,  it  should  be  distended  by  a  little 
water  injected  from  the  bulb.  This  water  is  retained  in  the 
bladder  by  closing  the  cock  of  the  evacuating-tube  ;  while 
the  bulb  is  replenished  through  the  small  hose. 

When  the  empty  evacuating  tube  is  first  introduced,  a  few 
bubbles  often  rise  from  it,  and  are  caught  in  the  bulb  by  ele- 
vating it ;  but  when  the  current  is  established,  air  takes  care 
of  itself,  and  goes  to  the  air  space  in  the  top  of  the  bulb.  In 
fact,  there  is  none  unless  by  accident.  By  opening  the  cocks 
and  compressing  the  abdomen,  it  is  easy  to  drive  all  air  out 
of  the  bladder  through  the  bulb. 

In  pumping,  only  a  couple  of  ounces  of  water  need  be 
moved  between  the  bladder  and  the  bulb,  backward  and 
forward  gently,  without  a  jerk,  once  in  a  second  or  two.  The 
tube  is  advantageously  held  just  off  the  floor  of  the  blad- 
der, —  a  little  higher  at  first,  when  the  debris  clogs  it,  and 
lower  when  only  a  few  fragments  remain. 


280  LITHOLAPAXY. 

As  regards  the  amount  of  time  necessary  for  an  operation 
under  ether,  take  as  much  as  is  necessary,  precisely  as  in 
an  amputation  or  excision.  I  usually  add  to  the  evacuation  a 
thorough  sounding.  This  requires  more  time.  Some  opera- 
tors leave  a  few  fragments  in  the  bladder,  to  make  the  sitting 
shorter ;  but  I  doubt  the  expediency  of  doing  so.  Great  care 
is  essential, —  also  practice.  How  to  pass  instruments,  large 
and  small,  curved  and  straight,  with  absolute  facility,  should 
be  learned  upon  the  dead  body  before  practising  upon  the 
living.  Notwithstanding  an  occasional  assertion  to  the  con- 
trary, I  am  sure  that  if  a  common  tin  sound  bent  successively 
into  a  variety  of  different  irregular  curves  can  be  introduced 
with  ease  into  the  bladder  of  a  dead  subject, — not  empirically, 
but  with  a  reason  for  each  movement  (and  a  few  hours'  in- 
telligent practice,  based  upon  anatomical  considerations,  will 
enable  this  to  be  done),  —  a  catheter  can  be  adroitly  passed 
in  any  difficult  case  upon  the  living  subject,  and  the  accidents 
avoided  that  sometimes  follow  the  introduction  of  common 
instruments,  such  as  laceration  of  the  mucous  membrane  and 
false  passage.  Obstructions  from  strictures  or  the  irregular 
walls  of  an  enlarged  prostate  will  also  be  skilfully  dealt  with.^ 

1  The  evacuator  of  Thompson  illustrates  the  objections  mentioned  in 
the  text.  Latterly  (Gazette  Hebdomadaire,  Oct.  31,  1879),  Thompson 
has  arranged  a  single  stop-cock  to  do  the  duty  of  two  in  closing  its 
lower  orifices  to  keep  the  bed  dry ;  but  the  instrument  is  virtually  the 
same.  (1)  The  bulb,  or  bottle,  like  Clover's,  is  above  the  catheter,  so  that 
the  water  has  to  be  drawn  up  into  it ;  and  if  the  cocks  happen  to  be  sim- 
ultaneously opened  for  a  moment,  it  will  all  run  into  the  bladder  and 
distend  it.  (2)  Its  weight  must  be  supported  by  the  operator,  or  rest 
upon  the  catheter.  (3)  Being  rigidly  fixed  to  the  catheter,  it  communi- 
cates the  jar  of  pumping  to  the  bladder,  —  this  old  "short  connection" 
thus  retained  between  catheter  and  bulb,  upon  which  Thompson  insists, 
yielding,  so  far  as  I  can  discover,  no  equivalent  advantage.  (4)  Lastly, 
the  mouth  of  the  catheter  enters  Imo  down,  into  the  narrowest  part  of  the 
bulb.  Consequently  fragments,  after  rising  into  the  bulb  with  the  cur- 
rent, must,  on  their  way  to  the  glass  trap,  again  crowd  in  front  of  the 
catheter;    and  thus  debris  is  needlessly  returned  to   the  bladder.      It 


LITHOLAPAXY.  281 

would  be  better,  if  it  be  desired  to  connect  the  catheter  low  down,  to 
prolong  it  a  couple  of  inches  inside  the  bulb,  and  to  let  the  fragments 
escape  at  a  higher  point,  where  the  cavity  is  wider,  as  is  represented  in 
the  lowest  tube  of  the  annexed  diagram  (Fig.  2).  With  such  an  instru- 
ment I  experimented  some  time  ago.  This  arrangement  also  keeps  the 
contents  of  the  trap  quiet,  and  there  is  no  return  of  fragments. 

But  even  an  imperfect  or  inconvenient  apparatus  may  suffice  to  empty 
the  bladder.  The  only  feature  of  an  evacuator  absolutely  essential  to 
rapid  lithotrity  is  the  large  evacuating  tube  I  have  elsewhere  described, 
which  Thompson  has  adopted  without  change.  It  is  this  that  enables  his 
instrument  to  evacuate.  The  want  of  this  large  catheter  (in  combina- 
tion with  good  suction  and  a  trap)  was  fatal  to  the  success  of  previous 
instruments,  and  to  all  attempts  at  the  immediate  evacuation  of  any 
considerable  amount  of  debris.  AVith  such  a  catheter  Clover's  instru- 
ment could  have  evacuated  the  bladder  slowly,  and  might  have  led,  in 
the  face  of  traditional  prejudice,  to  the  discovery  of  the  tolerance  of  that 
organ,  and  of  lithotrity  at  a  single  sitting.  But  the  catheter  of  Clover's 
instrument  was  too  small,  being  only  21  French  (12  English),  beyond 
which  the  English  scale  did  not  go.  Its  eye  was  also  defective.  The 
new  method  was  impossible  to  those  who  were  using  this  small  catheter. 
They  could  not  empty  the  bladder  of  all  its  fragments,  and  therefore 
knew  nothing  of  its  great  recuperative  powers  after  the  complete  removal 
of  this  source  of  irritation.  Authorities  agreed  that  evacuating  instru- 
ments were  worthless.  AVhen  Otis  directed  the  attention  of  surgeons  to 
the  fact  (see  a  pa])er  by  R.  F.  Weir  in  the  New  York  Medical  Journal, 
April,  1876)  that  the  capacity  of  the  average  urethra  was  very  nearly  33, 
rapid  lithotrity  was  made  easy.  Sittiiigs  were  lengthened  from  a  few 
minutes  to  an  hour  or  two. 


282  LITHOLAPAXY. 

LITHOLAPAXY. 

FROM    A   CLINICAL   LECTURE.^ 

Gentlemen,  —  Within  ten  days  we  have  had  two  cases  of 
litholapaxy,  one  of  which  you  saw.  After  both,  the  tempera- 
ture rose  from  98°  to  above  100°  F.  On  the  third  day  it 
fell  to  99°  F.,  and  now,  three  days  later,  it  is  normal.  This 
reaction  is  like  that  from  the  effect  of  a  bougie,  and  the 
temperature  like  that  of  urethral  fever.  A  patient  readily 
recovers  from  the  operation  of  litholapaxy  if  we  remove  from 
the  bladder  all  the  fragments  of  the  stone.  In  fact,  the  new 
method  has  succeeded  beyond  expectation. 

Small  stones  are  easily  ground  up,  especially  if  soft,  and 
then  come  away  of  themselves.  Serious  consequences  may 
follow  if  fragments  are  left  in  the  bladder.  In  former  times 
cases  that  did  not  admit  of  lithotrity  had  to  be  cut ;  likewise 
those  in  which,  from  any  reason,  lithotrity  was  hazardous. 
A  recent  number  of  the  London  "Lancet"  reports  a  case  in 
which  Mr.  Smith,  of  St.  Bartholomew,  removed  four  ounces 
of  stone  from  the  bladder  of  an  elderly  man,  who  left  the 
hospital  in  a  week.  This  is  the  largest  quantity  of  debris 
ever  removed  by  litholapaxy. 

The  operation,  of  course,  is  purely  mechanical,  and  any 
reference  to  it  is  chiefly  to  its  mechanics.  The  principles  of 
litholapaxy  and  of  complete  evacuation  are  pretty  well  settled 
and  accepted.  It  is  now  mainly  a  question  of  certain  minor 
details  of  convenience  in  the  apparatus.  I  am  satisfied  that 
one  point  which  contributes  as  much  as,  if  not  more  than,  any 
other  to  rapid  and  complete  evacuation  is  the  power  of  regu- 
lating and  of  frequently  varying  the  quantity  of  water  in  the 

*  The  Boston  Medical  and  Surgical  Journal,  March  4,  1880. 


LITHOLAPAXY.  283 

bladder.  You  require  just  enough  water  to  prevent  the  thud 
of  the  slack  walls  when  they  are  drawn  into  the  eye  of  the 
catheter.  When  you  feel  that,  the  bladder  must  have  a  little 
more  water  to  distend  it.  Too  little  water  crowds  the  fras- 
ments  together.  When  there  is  too  much,  you  may  have  to 
chase  a  single  fragment  a  long  time. 

The  arrangement  of  hose  I  show  you  here  is  the  only  one 
that  allows  the  operator  to  diminish  the  quantity  of  water  in 
the  bladder  without  disturbing  the  apparatus.  If  one  end  of 
this  hose,  which  is  not  much  larger  than  a  pipe-stem,  be 
kept  in  a  tumbler  of  water  it  does  not  in  the  least  interfere 
with  the  convenience  of  the  operator ;  but  on  the  other 
hand  it  does  enable  him,  by  turning  the  cocks,  to  vary  from 
one  minute  to  another,  if  he  please,  the  amount  of  water  in 
the  bladder.  There  can  be  no  doubt  of  the  advantage  of 
being  able  to  do  so. 

Another  point  relates  to  the  size  of  the  tubes.  The  small- 
est tube  used  in  litholapaxy  is  larger  than  the  largest  tube 
that  was  used  for  evacuation  in  previous  operations.  But  you 
will  find  that  the  largest  tubes  I  use  are  sometimes  not  pre- 
ferred by  other  surgeons.  They  are  in  the  habit  of  using  a 
No.  28  or  29  tube,  and  these  often  serve  the  purpose.  The 
fact  is  this :  a  stone  after  evacuation  is  found  to  have  been 
mostly  reduced  to  powder  and  minute  fragments ;  large 
fragments  are  rather  the  exception.  Now,  the  fine  deljris 
may  be  evacuated  through  a  28  or  29  tube,  though  perhaps 
not  quite  so  rapidly  as  if  the  tube  had  a  calibre  of  30  or  31. 
It  then  remains  only  to  crush  the  larger  fragments  and  re- 
peat the  process.  I  prefer  a  larger  tube,  when  there  is  no 
objection  to  its  introduction,  because  it  not  only  evacuates  the 
dust  more  rapidly,  but  at  the  same  time  allows  me  to  remove 
the  large  fragments  without  having  to  crush  them  again. 

I  am  sure  that  in  the  end  operators  will  all  use  a  stand  to 
support  the  weight  of  the  bulb,  because  it  is  very  inconvenient 


284  LITHOLAPAXY. 

to  hold  it  through  a  long  operation.  But  there  should  be  a 
device  (as  in  the  stand  I  show  you  here)  for  supporting  the 
bulb  at  different  heights,  which  can  be  varied  during  the 
progress  of  evacuation. 

I  also  think  surgeons  will  connect  the  bulb  with  the  evac- 
uating catheter  by  means  of  an  elastic  tube,  so  that  one  can 
be  moved  without  the  other.     This  to  me  is  a  sine  qua  non. 


DE   LA  LITHOLAPAXIE.  285 


DE  LA   LITHOLAPAXIE; 

OU,   LITHOTRITIE   AVEC    EVACUATION   IMMEDIATE    EN   UNE   SEULE 

SEANCE. 1 

II  s'agit  ici  d'une  modification  de  la  lithotritie,  ayant  pour 
effet  de  reuverser  les  traditions  qui  avaient,  jusque  dans  ces 
derniers  temps,  regie  cette  operation,  et  de  la  rendre  applica- 
ble a  des  calculs  plus  volumineux  que  ceux  qu'on  avait  eu 
I'habitude  d'operer  par  la  methode  du  broiement.  Ce  me- 
moire  a  pour  but  d'exposer  brievement  I'historique  de  la 
decouverte  du  procede  nouveau,  et  de  decrire  I'appareil  in- 
strumental au  moyen  duquel  il  a  pu  etre  mis  a  execution. 
Certains  perfectionnements  port^s  a  cet  appareil  se  trouvent 
decrits  ici  pour  la  premiere  fois. 

La  methode  nouvelle  qui  se  trouve  exposee  dans  ce  me- 
moire  est  basee  sur  un  fait  nouveau :  a  savoir,  la  tolerance 
inattendue  qu'oiTre  la  vessie  pour  les  manoeuvres  instrumen- 
tales  prolongees  de  la  lithotritie  avec  evacuation.  Au  moyen 
du  nouvel  appareil  qui  se  trouvera  decrit  plus  loin,  et  qui  est 
le  seul  qui  ait  permis  d'atteindre  de  pareils  resultats,  on  pent 
maintenant  evacuer  completement,  en  une  seule  seance,  les 
debris  d'un  calcul  de  volume  considerable. 

En  presentant  une  methode  operatoire  nouvelle,  dont  les 
principaux  details  sont  cependant  deja  connus  du  monde 
medical  depuis  pres  de  trois  ans,  I'auteur  a  cru  qu'il  serait 
superflu  de  soumettre  a  I'Acaddmie  de  Medecine  un  travail 
complet  et  circonstancie  ou  tons  les  details  ayant  trait  a  son 
procede  se  trouveraient  exposes.  II  a  pense  qu'il  se  confor- 
merait  mieux  aux  d^sirs  de  I'Acad^mie  en  se  contentant  de 

1  Memoire  soumise  au  Comite  de  rAcademie  de  Medecine  de  France, 
poiir  le  prix  d'Argenteuil  de  I'annee  1881. 


286  DE   LA  LITHOLAPAXIE. 

presenter  une  description  sommaire  de  sa  methode  et  de  son 
appareil  instrumental. 

Civiale,  apres  plusieurs  essais,  parvint  a  am^liorer  ses  in- 
struments de  telle  sorte  qu'il  put  atteindre  un  resultat  qu'a 
tort  il  avait  cru  avantageux,  consistant  a  restreindre  la  seance 
de  litbotritie  a  une  duree  de  quelques  minutes.  Chose  singu- 
liere,  depuis  cette  ^poque-la  jusque  vers  I'annde  1878,  les 
chirurgiens  se  sont  fourvoyds  en  cherchant  a  depasser  les 
resultats  ainsi  atteints  par  Civiale  et  en  abri^geant  encore 
davantage  la  dur^e  de  la  stance.  On  s'est  imaging  que  les 
stances  de  tres  courte  duree  temoignaient  de  I'adresse  du 
chirurgien,  tout  en  rendant  I'operation  moins  dangereuse  pour 
le  malade.  Ainsi,  Sir  Henry  Thompson  recommandait  a  ses 
Aleves  de  ne  pas  depasser  pour  chaque  seance  une  duree  de 
trois  minutes,  tout  en  leur  faisant  remarquer  que,  gr^ce  a 
une  habilet^  manuelle  particuliere,  il  avait  lui-meme  pour 
habitude  d'accomplir  la  besogne  d'une  seance  de  broiement 
en  un  espace  de  temps  nioitie  moindre.  II  ^tait  alors  con- 
venu  que  la  duree  d'une  seance  ne  devait  pas  depasser  un 
nombre  de  minutes  tres  limite.  Maintenant,  cependant,  des 
operations  ayant  une  durde  d'une  demie  heure  sont  com- 
munes, et,  dans  un  cas  exceptionnel  a  cet  ^gard,  I'operation, 
suivie  d'ailleurs  d'un  heureux  resultat,  a  eu  une  duree  de 
plus  de  trois  hcures. 

Cette  innovation  si  frappante  s'explique  de  la  maniere  sui- 
vante.  La  vessie  est  nioins  sujette  a  etre  lesee  par  le  contact 
d'instruments  metalliques  arrondis  et  lisses,  convenablement 
manids,  que  par  la  presence  des  fragments  anguleux  qu'on 
avait  autrefois  I'habitude  de  laisser  sejourner  dans  sa  cavite 
pendant  toute  la  dur(3c  du  traitement  par  la  lithotritie.  La 
vessie  tolere  de  bonne  gr^ce  une  operation  prolongee  pourvu 
qu'elle  ait  pour  resultat  I'ablation  complete  des  fragments. 
Pendant  une  cinquantaine  d'ann^es,  il  n'existait  aucun  appa- 
reil qui  permit  d'opdrcr  I'extraction  des  fragments  a  travers 


DE   LA  LITHOLAPAXIE.  287 

les  voies  naturelles.  II  etait,  par  consequent,  impossible  do 
determiner,  d'une  maniere  quelque  pen  precise,  jusqu'a  quel 
point  la  vessie  pourrait  tolerer  les  manoeuvres  chirurgicales. 
Pendant  un  demi-siecle,  il  n'existait  a  ce  sujet  que  des 
notions  tout-a-fait  erronees. 

Le  procede  nouveau,  grace  auquel  I'auteur  de  ce  memoire, 
il  y  a  pres  de  quatre  ans,  fit  la  d^couverte  du  degrd  de  tole- 
rance offerte  par  la  vessie  pour  les  manoeuvres  prolongees,  fut 
I'emploi  d'une  grosse  sonde  evacuatrice  ayant  le  calibre  de 
I'urethre  normal,  c'est-a-dire,  entre  les  num^ros  25  et  31  de 
la  filiere  Charriere,  au  lieu  d'un  calibre  ne  d^passant  pas  le 
numero  21,  comme  celui  de  la  sonde  qui  fait  partie  de  I'appa- 
reil  a  aspiration  de  Clover.  II  fallait,  en  outre,  un  moyen 
efficace  quelconque  pour  retenir  les  fragments  qui  auraient 
etc  entraines  a  travers  la  sonde  et  pour  empecher  leur  retour 
dans  la  vessie. 

Une  forte  sonde  de  calibre  suffisant,  d'une  part,  et  un  ap- 
pareil  destine  a  empecher  le  retour  des  fragments  dans  la 
vessie,  d'autre  part,  constituent  done  les  parties  absolument 
indispensables  de  I'instrument  evacuateur.  Une  poire  elas- 
tique  en  caoutchouc  constitue  le  meilleur  moyen  de  propulsion 
pour  communiquer  a  I'eau  d'injection  le  mouvement  requis  de 
va-et-vient ;  mais,  a  vrai  dire,  I'agencement  reciproque  des 
parties  constituantes  essentielles  de  I'appareil,  —  a  savoir,  forte 
sonde,  reservoir,  et  poire  elastique,  —  peut  varier  de  toutes 
les  fa9ons,  selon  les  preferences  de  chacun;  du  reste,  les 
diverses  manieres  de  combiner  ces  elements  ont  au  fond  i^eu 
d'importance. 

Je  me  permettrai  d'ajouter  ici  quelques  details  relativement 
a  chacune  de  ces  parties  constituantes  principales  d'un  appa- 
reil  evacuateur  efficace  et  commode  tel  que  je  le  consols. 

II  s'agira  d'abord  de  la  sonde,  —  dont  le  calibre  pourra 
varier  entre  les  numeros  25  et  31,  —  qui  a  ete  imagin^e  pour 
cette  nouvelle  m^thode  de  lithotritie  avec  evacuation  immedi- 


288  DE   LA   LITHOLAPAXIE. 

ate.  Get  instrument  pent  etre  droit  ou  courb^,  selon  le  gout 
ou  les  habitudes  du  chirurgien.  Quoi  qu'il  en  soit  a  cet  egard, 
il  doit  etre  muni  d'un  oeil  arrondi,  situe  tout  aupres  de  son 
extr^mit^,  et  ayant  un  calibre  non  moindre  que  la  lumiere 
interieure  de  I'instrument.  Le  bee  doit  etre  un  pen  prolonge, 
en  forme  de  levre  arrondie,  pour  faciliter  le  cheminement  de 
I'instrument  a  travers  le  canal.  La  sonde  ainsi  conformee  a 
et^  adoptee  partout  sans  modification  aucune. 

Tous  les  appareils  ^vacuateurs  qu'on  avait  deja  imagines 
avaient  I'inconvenient  de  r^injecter  dans  la  vessie  un  certain 
nombre  des  fragments  qui  en  avaient  ete  extraits,  defaut  qui 
rendait  I'operation  plus  longue  et  le  succes  d^finitif  moins 
certain.  J'ai  completement  rem^di^  a  cette  imperfection  en 
ajoutant  un  petit  reservoir  avec  soupape,  s'adaptant  au  pavil- 
ion de  la  sonde,  de  telle  sorte  que  les  fragments,  ayant  par- 
couru  toute  la  longueur  de  la  sonde  et  franchi  son  orifice 
extra-vesical,  ne  peuvent  plus  rentrer  dans  la  vessie. 

Ce  reservoir  se  compose  d'un  petit  cylindre  creux  en  verre, 
a  I'intdrieur  duquel  se  meut,  sans  bruit,  une  boule  en  caout- 
chouc faisant  soupape,  en  s'acculant,  pendant  la  compression 
de  la  poire,  contre  un  grillage  en  entonnoir  qui  laisse  passer 
I'eau,  tout  en  s'opposant  au  rctour  des  fragments  dans  la 
vessie.  Ce  detail  de  I'appareil,  qui  n'avait  pas  encore  et^ 
d^crit,  est  pour  moi  presqu'aussi  important  que  la  grosse 
sonde  ^vacuatrice. 

La  bouteille  en  caoutchouc  doit  avoir  plus  de  resistance, 
plus  de  force  ^lastique  que  celle  de  Clover.  Elle  s'adapte 
a  la  sonde  par  I'interm^diaire  d'un  court  tube  en  caoutchouc, 
gr^ce  auquel  la  sonde  et  la  bouteille  peuvent  se  mouvoir  inde- 
pendamment  Tune  de  I'autre.  La  poire  pent  reposer  a  la 
hauteur  voulue  sur  un  support  quelconque,  et  grace  a  celui-ci 
et  de  I'interposition  du  tube  de  caoutchouc,  le  chirurgien  peut 
s'^pargner  la  fatigue  de  supporter  le  poids  considerable  de 
I'appareil  rempli  d'cau  pendant  toute  la  dur^e  de  son  emploi. 


DE   LA  LITHOLAPAXIE.  289 

La  bouteille  a  ime  forme  spherique,  et  la  sonde  s'adapte  sur 
son  ^quateur.  Si  par  hasard  il  venait  a  penetrer  de  Fair  dans 
I'appareil,  il  irait  de  suite  se  loger  au  sommet  de  la  poire, 
tandis  que  les  fragments  se  trouveraient  entraines  par  leur 
poids  vers  le  fond.  L'air  accumule  en  volume  suffisant  pour 
gener  I'operateur  peut  de  suite  etre  expulse  a  travers  un  petit 
tube  avec  robinet  qui  surmonte  la  poire.  Le  chirurgien  peut 
alors  remplacer  cet  air  par  de  I'eau  qu'il  aspire  en  sens 
inverse  a  travers  ce  meme  tube. 

Les  fragments,  ayant  franchi  le  trajet  a  travers  la  sonde  et 
etant  parvenus  jusque  dans  I'interieur  de  la  poire,  tombent 
dans  le  reservoir  transparent  qui  se  trouve  place  sous  celle-ci. 
Ce  reservoir  peut  etre  facilement  detache  lorsqu'on  desire 
extraire  son  contenu. 

Tout  brise-pierre  suffira,  a  la  rigueur,  a  effectuer  le  broie- 
ment  de  la  pierre,  pourvu  qu'il  soit  d'une  force  suffisante.  II 
ne  s'agit  pas  ici  de  la  maniere  dont  il  faut  s'y  prendre  pour 
I'introduire  dans  la  vessie.  Je  me  contenterai  de  faire  re- 
marquer  qu'un  instrument  d'un  volume  excessif  ne  peut  pas 
etre  conduit  a  travers  I'urethre  sans  danger ;  et  que  I'urethre 
profond  et  le  col  vesical  toldrent  encore  moins  que  la  vessie 
les  lesions  traumatiques  qui  pourraient  etre  infligees  pendant 
I'operation. 

Puisque  le  chirurgien  se  propose  a  present  d'achever  le 
broiement  du  calcul  en  une  seule  stance,  afin  de  pratiquer 
I'extraction  immediate  des  debris,  il  est  devenu  fort  avanta- 
geux  de  se  trouver  muni  d'un  brise-pierre  pouvant  fonction- 
ner  longtemps  dans  la  vessie  sans  que  les  mors  soient  sujets 
a  s'engorger.  J'ai  done  ete  conduit  a  imaginer  une  conforma- 
tion particuliere  des  mors  qui  rend  leur  engorgement  impossi- 
ble. A  cet  effet,  le  mors  male  de  mon  brise-pierre  presente, 
sur  la  surface  qui  se  porte  a  I'encontre  du  mors  femelle,  une 
s^rie  d'encoches  laterales,  a  plans  inclines  dirigds  alternative- 
ment  a  droite  et  a  gauche.     J'ai  egalement  fait  construire  un 

19 


290  DE  LA  LITHOLAPAXIE. 

instrument  a  mors  fenetr^  qui  broie  sans  s'engouer.  II  'est 
pas  avantageux  de  se  servir  du  brise-pierre  pour  extrairc  les 
debris  du  calcul.  Leur  ablation  s'opere  d'une  maniere  plus 
salutaire  par  Taspiration  a  travers  la  sonde  que  par  I'extrac- 
tion  au  moyen  du  brise-pierre,  dont  les  mors,  lorsqu'ils  sont 
charges  de  debris  et  entr'ouverts,  peuvent  infliger  aux  parois 
urethrales  des  lesions  tres  graves,  sinon  fatales.  Afin  d'em- 
pecher  I'engouement,  qui  est  surtout  sujet  a  se  produire  a  Tan- 
gle du  mors  femelle,  j'ai  fait  pratiquer  dans  cet  endroit  une 
fenetre  assez  large,  destinee  a  etre  completement  traversee  par 
I'angle  de  la  branche  male  se  prolongeant  en  forme  de  talon, 
et  repoussant  devant  lui  les  debris  du  calcul.  Pour  augmenter 
la  force  de  I'instrument,  sans  toutefois  nuire  a  la  facility  de 
son  introduction,  j'ai  fait  construire  les  mors  avec  un  coude 
depassant  de  bien  pen  de  degres  Tangle  droit ;  et,  finalement, 
pour  rendre  le  bee  de  I'instrument  aussi  inoffensif  que  possible 
pour  les  parties  a  travers  lesquelles  il  doit  cheminer  pendant 
son  introduction,  et  surtout  pour  garantir  la  parol  supdrieure 
de  Turethre,  j'ai  fait  leg^rement  allonger,  infl^chir  en  avant, 
et  arrondir  Textr^mite  du  mors  femelle.  Cette  conformation 
nouvelle  ne  nuit  aucunement  a  Tefficacit^  des  prises  oper^es 
par  le  chirurgien. 

J'ai  encore  modifie  la  poign(3e  du  brise-pierre  d'une  maniere 
que  je  crois  avantageuse,  en  y  adaptant  des  armatures  nouvelles 
de  deux  especes,  destinies  a  faciliter  son  maniement,  II  s'agit 
toujours  du  brise-pierre  usuel,  a  vis  et  a  ^crou  bris^,  avec 
poignde  a  barillet  cylindrique.  Dans  Tun  de  mes  brise-pierres 
le  chirurgien  fait  fonctionner  Tecrou  bris^  au  moyen  d'un  an- 
neau  qui  entoure  le  barillet,  et  auquel  on  communique  avec  les 
doigts  de  la  main  droite  un  mouvement  de  va-et-vient,  en  le 
faisant  glisser  dans  les  deux  sens,  longitudinalement.  L'autre 
brise-pierre,  dont  le  mdcanisme  differe  de  tous  ceux  qu'on 
avait  deja  imagines,  fonctionne  par  Tinterm^diaire  d'une  arma- 
ture a  rotation  dont  le  jeu  altcrnaftif  dans  les  deux  sens,  dex- 


DE   LA  LITHOLAPAXIE.  291 

tro :  um  et  sinistrorsum,  en  quart  de  cercle,  est  effectu^  par 
les  doigts  de  la  main  droite.  L'ouverture  et  la  fermeture  de 
I'ecrou  brise  s'op^re  ainsi  tres  facilement,  sans  effort  et  sans 
tatonnements  des  doigts,  au  moyen  de  mouvements  tres  natu- 
rels  de  pronation  et  de  supination  de  la  main  droite,  du  meme 
genre  que  ceux  qui  servent  a  faire  marcher  la  vis  du  brise- 
pierre.  J'aime  a  croire  qui  cette  poignee  finira  par  remplacer 
toutes  celles  qui  ont  ete  imaginees  jusqu'a  present. 

En  faisant  penetrer  un  instrument  quelque  peu  volumineux, 
le  chirurgien  doit  veiller  a  ne  pas  violenter  la  partie  profonde 
de  I'urethre.  Le  broiement  peut  continuer  jusqu'a  ce  que  les 
debris  se  soient  accumules  en  quantity  suffisante  pour  gener  le 
jeu  du  brise-pierre.  Pourvu  que  les  forces  du  malade  ne  soient 
pas  trop  delabrees,  il  n'est  point  necessaire,  pas  plus  que  dans 
tout  autre  genre  d'ope rations,  d'imposer  d'avance  des  limites 
precises  a  la  duree  totale  de  la  seance. 

Le  broiement  du  calcul  ayant  ete  effectue,  le  brise-pierre 
est  retire,  la  sonde  ^vacuatrice  est  introduite,  et  la  bouteille 
en  caoutchouc  est  adaptee  a  son  extremite  extra-vesicale.  Un 
lien  elastique  est  alors  fix^  autour  de  la  verge  pour  empecher 
la  vessie  d'expulser  son  contenu  liquide ;  en  tatant  la  paroi 
inferieure  de  I'urethre  derriere  cette  ligature,  le  chirurgien 
peut,  jusqu'a  un  certain  point,  apprecier  le  degre  de  la  disten- 
sion subie  par  la  paroi  vesicale.  La  quantite  d'eau  a  employer 
varie  naturellement  selon  la  capacity  de  la  vessie.  II  suffit 
que  la  vessie  soit  suffisamment  distendue  d'eau  pour  empecher 
I'aspiration  de  sa  paroi  trop  flasque  centre  I'oeil  de  la  sonde ; 
lorsque  ce  phenomene  vient  a  se  produire,  le  chirurgien  en  est 
averti  de  suite  par  une  serie  de  petites  secousses  transmises  a 
la  sonde  et  meme  a  la  bouteille  en  caoutchouc  au  moment  oii 
I'aspiration  s'exerce ;  il  suffit  alors  de  distendre  davantage  la 
vessie  en  y  ajoutant  une  certaine  quantite  d'eau,  que  I'on  peut 
puiser  dans  un  vase  au  moyen  du  petit  tube  situ^  au  sommet 
de  la  bouteille. 


292  DE  LA  LITHOLAPAXIE. 

L'evacuation  a  lieu  d'une  fagon  tres  simple  et  facile,  au 
moyen  de  petits  mouvements  de  va-et-vient  communiques  au 
contenu  de  la  vessie  par  I'intermediaire  de  la  sonde,  et  produits 
par  la  compression  et  par  I'expansion  de  la  poire  elastique. 
Les  fragments  du  calcul  ne  tardent  pas  a  se  faire  voir  et  a 
s'accumuler  dans  le  reservoir  en  verre.  La  sonde  est  tenue 
d'abord  de  maniere  a  ce  que  I'oeil  soit  un  pen  ^leve  au-dessus 
du  bas-fond  vesical ;  plus  tard,  et  au  fur  et  a  mesure  que  les 
fragments  deviennent  moins  abondants  dans  la  vessie,  le  bee 
doit  etre  abaiss^  de  plus  en  plus.  Les  fragments  trop  gros 
pour  traverser  la  sonde  viennent  heurter  contre  les  rebords 
de  I'ceil  avec  un  cliquetis  facile  a  percevoir,  et  exigent  alors 
un  nouveau  broiement. 

La  recherche  d'un  dernier  fragment  de  faible  volume,  ou 
d'un  petit  calcul,  s'effectue  mieux  au  moyen  de  cet  appareil  a 
aspiration  qu'avec  la  sonde  exploratrice  qu'on  a  I'habitude 
d'employer  pour  reconnaitre  la  presence  de  calculs  ou  de 
fragments  dans  la  vessie.  Grace  a  I'emploi  de  I'aspiration 
le  fragment  vient  a  la  rencontre  de  I'instrument  explorateur. 
Celui-ci  I'evacue  de  suite,  ou  bien  fait  savoir  au  chirurgien 
que  le  broiement  sera  de  nouveau  requis  pour  venir  a  bout  de 
ce  fragment  encore  trop  volumineux. 

Telle  est  ma  nouvelle  m^thode  de  lithotritie  rapide  en  une 
seule  stance.  Je  peux  dire  que  cette  operation  a  reqn  un 
accueil  favorable  presqu'universel  en  Europe  comme  en  Am^- 
rique.  On  n'entend  presque  plus  aujourd'hui  de  voix  dissi- 
deutes  a  ce  sujet.  Les  calculs  petits  et  moyens  se  laissent 
facilement  broyer  et  ^vacuer  en  une  seule  operation.  Des 
pierres  plus  volumineuses  ont  6t6  traitdes  de  la  meme  fa9on, 
et  la  gudrison  des  malades  a  et6  prompte  et  complete.  Porter, 
Thomas  Smith,  Teevan,  Green,  et  d'autres  chirurgiens  encore, 
ont  rapports  des  cas  heureux  ou  les  quantitds  de  debris  dva- 
cuds  par  ce  procddd,  en  une  ou  deux  stances,  d'une  a  trois 


DE   LA  LITHOLAPAXIE.  293 

heures  de  duree,  out  varie  entre  mille  et  pres  de  deux  mille 
grains  (de  65  a  120  grammes  environ).  Ces  faits  si  frappants 
t^moignent  de  la  revolution  complete  qui  s'est  operee  dans 
nos  esprits  relativement  aux  limites  qui  doivent  maintenant 
etre  imposees  a  la  lithotritie.  II  n'est  pas  encore  possible  de 
prevoir  jusqu'a  quel  point  la  methode  nouvelle,  que  je  viens 
de  decrire  d'une  fagon  tres  sommaire,  pourra,  chez  I'adulte, 
remplacer  la  taille ;  les  donnees  existantes  ne  su£Qsent  pas 
encore  pour  que  nous  pouissions  determiner  I'^tendue  du 
champ  dans  lequel  elle  pourra  §tre  employee  avec  profit. 

J'ai  propose  pour  cette  methode  de  broiement  avec  evacua- 
tion d'emblee  des  fragments  le  nom  de  litholaj^axie.  Nous 
pourrions,  cependant,  nous  passer  de  ce  neologisme,  peut-etre 
quelque  peu  cacophone,  si  la  vieille  lithotritie  de  Civiale,  en 
seances  courtes  et  multipliees,  venait  a  etre  abandonnee.  La 
lithotritie,  quelles  que  puissent  etre  les  modifications  qu'elle 
subira,  sera  toujours  la  lithotritie,  —  mais  dorenavant  cette 
methode,  je  crois,  sera  caracteris^e  par  I'evacuation  immediate 
et  complete  des  fragments  tout  autant  que  par  le  broiement  de 
la  pierre,  qui  autrefois  constituait  a  lui  seul  toute  I'operation. 

Certaines  complications  preexistantes  peuvent  donner  lieu 
a  des  indications  particulieres.  Le  meat  urethral,  qui  consti- 
tue  generalement  le  point  le  plus  ^troit  du  canal,  doit  souvent 
etre  elargi  au  moyen  d'une  petite  incision,  pratiquee  au  moyen 
d'un  bistouri  boutonne,  ou  bien  avec  des  ciseaux.  C'est  la 
une  operation  insignifiante. 

D'autre  part,  il  est  parfois  n^cessaire,  dans  certains  cas,  de 
pouvoir  ecarter,  seance  tenante,  I'obstacle  constitue  par  un 
retrecisseraent  urethral  plus  profondement  situe.  La  divul- 
sion  s'est  trouvee  etre  un  excellent  moyen  pour  atteindre  ce 
bout ;  et,  a  cet  effet,  j'ai  quelque  peu  modifie  I'instrument  qui 
etait  affects  h  cette  operation.  Mon  divulseur  est  ainsi  con- 
stitue :  la  bougie  filiforme  conductrice  s'attache  comme  d'or- 


294 


DE   LA  LITHOLAPAXIE. 


dinaire,  par  un  pas  de  vis,  a  un  mandrin  metallique  droit. 
Celui-ci  sert  de  conducteur  a  une  longue  et  forte  olive  metal- 
lique qui,  ainsi 
que  la  tige  en 
tube  qui  lui  sert 
de  manche  et  de 
moyen  de  pro- 
pulsion, est  per- 
force dans  toute 
sa  longueur  d'un 
canal  central,  de 
maniere  c\  pou- 
voir  cheminer 
par  glissement 
le  long  du  man- 
drin conducteur, 
en  dilatant  les 
points  rCtrCcis  du 
canal  de  I'ure-^ 
thre.  Pour  pra- 
tiquer  la  divul- 
sion,  on  intro- 
duit  d'abord  le 
mandrin  droit 
central  a  la  suite 
de  la  bougie  fili- 
forme.  Ce  man- 
drin conducteur 
est  immobilisC 
pendant  le  cheminement  d'avant  en  arri^re  de  I'olive  dila- 
trice  a  travers  les  points  rCtr«^cis,  au  moyen  d'une  sorte  de 
pavilion  en  forme  d'hemisphere  creuse,  qui  coiife  le  gland,  en 
appuyant  contre  celui-ci,  et  fournit  ainsi  un  point  d'appui. 
1  Divulseur  Bioelow. 


Fu..  v. 


DE  LA  LITHOLAPAXIE.  295 

L'operateur,  etreignant  la  verge  de  la  main  gauche,  pousse 
I'olive  le  long  du  mandrin  conducteur  central  de  la  main 
droite,  pendant  que  la  propulsion  en  avant  de  celui-ci  est  em- 
pech^e  par  le  pavilion  evase  qui  coiffe  le  gland  et  s'y  appuie. 
II  y  a  en  outre  certains  details  qu'il  serait  inutile  de  decrire  ici. 
II  suffit  d'inspecter  I'instrument  pour  comprendre  de  suite  sa 
construction  et  la  maniere  de  s'en  servir.  Je  me  contente- 
rai  de  dire  que  cet  instrument  a  divulsion  a  I'avantage  sur 
ceux  qui  existaient  deja,  de  n'exiger  pour  son  maniement 
qu'une  seule  paire  de  mains,  et  qu'il  remplit  parfaitement  le 
but  pour  lequel  il  a  ete  imagine. 

Tels  sont  I'appareil  instrumental  nouveau  et  la  mdthode 
operatoire  nouvelle  pour  le  traitement  des  calculs  vesicaux 
que  j'ai  I'honneur  de  soumettre,  tres  respectueusement,  a  Fap- 
preciation  du  Comite  de  I'Academie  de  Medecine  pour  le 
prix  d'Argenteuil  de  I'ann^e  1881. 


296  MODERN  LITHOTRITY. 


MODERN  LITHOTRITY.i 

My  object  in  the  present  communication  is  to  show  in  what 
the  modern  operation  of  lithotrity  consists,  and  to  explain 
the  instruments  which  liave  made  its  performance  possible ; 
for  the  removal  of  a  vesical  calculus  through  the  urethra  is 
now  mainly  a  question  of  apparatus,  of  which  certain  essential 
details  are  new.  And  as  it  is  by  no  means  necessary  that 
the  different  parts  of  the  apparatus  should  be  put  together 
exactly  in  any  particular  manner,  it  will  be  perhaps  better  to 
illustrate  the  principles  of  its  construction  than  to  insist  on 
any  special  form  of  it.  It  will  also  be  unnecessary  for  me  to 
dwell  on  those  parts  of  the  subject  which  belong  as  well  to 
the  old  lithotrity  as  to  the  new. 

From  the  days  of  Civiale  to  the  year  1878  there  was  little 
change  in  the  operation.  The  duration  of  a  sitting  was  as 
brief  as  the  skill  of  the  surgeon,  stimulated  by  his  fear  of 
producing  cystitis,  could  make  it.  Three  minutes  or  less 
was  the  limit  inculcated  by  standard  books  and  teaching  of 
specialists,  and  the  use  of  anassthesia  was  exceptional.  At 
present  anaesthetics  are  the  rule.  The  instruments  have 
been  already  modified  in  an  important  manner,  while  sit- 
tings often  last  half  an  hour,  and  have  been  successfully 
extended  to  three  hours  and  more. 

Had  Clover  (whose  catheter  had  a  calibre  only  21  of  the 
French  standard,  —  about  12  English)  or  Mercier  employed 
larger  catheters  (between  25  and  31  French,  — 15  to  20 
English),  they  might  liave  evacuated  the  bladder  completely. 
They  would  have  found  how  little  affected  it  was  by  a  long 
operation  if  no  fragments  were  left  behind,  and  that  polished 

^  Transactions  of  The  International  Congress  of  Physicians  and  Sur- 
geons, Seventh  Session ;  Vol.  II.,  pp.  292-306,  London,  1881. 


MODERN  LITHOTRITY. 


297 


instruments  were  not  injurious  to  it,  while  sharp  fragments 
were.  They  would  have  discovered  a  toleratice  on  the  part  of 
the  bladder  wholly  at  variance  with  the  traditions  of  half  a 
century.     Upon  this  tolerance  modern  lithotrity  is  based. 

The  new  and  essential  instrument  of  the  operation  is  the 
large  catheter  (25  to  31),  whether  straight  or  curved  (Fig.  1). 
This  is  indispensable.  It  has  an  orifice  at  the  extreme  end,  one 
side  of  which  is  prolonged  so  as  to  make  its  introduction  easy. 


Fig.  1.1 

It  has  been  adopted  with  little  or  no  change,  so  far  as  I  know, 
everywhere.  Although  my  first  apparatus  was  provided  with 
efficient  means  of  suction  and  a  detached  trap,  neither  of 
which  was  used  before,  its  distinctive  feature  was  the  large 
catheter.  The  small  size  of  the  previous  evacuating  catheter 
delayed  surgical  progress  for  half  a  century.  All  the  frag- 
ments could  not  pass  through  it,  and  it  was  impossible  for 
surgeons  to  ascertain  how  the  bladder  would  behave  when 
once  completely  emptied  of  all  fragments. 

Assuming  all  this  to  be  admitted,  let  us  examine  the  rest 
of  the  apparatus,  and  see  how  the  operation  is  modified  by  it. 

1  Large  and  small  evacuating  catheters,  straight  and  curved  (Nos.  25 
and  31  French). 


298 


MODERN  LITHOTRITY. 


As  even  a  single  minute  fragment  left  in  the  bladder  may  be 
the  micleus  of  a  future  stone,  it  is  important  to  get  rid  of  it 
with  certainty,  and  once  for  all.     Now,  although  a  fragment 

remaining  in  the  catheter  after 
the  bulb  has  ceased  to  expand 
goes  back  to  the  bladder,  yet  if 
it  has  once  passed  beyond  the  ca- 
theter, its  return  to  the  bladder 
ought  to  be  made  impossible  :  the 
surgeon  should  be  able  to  secure 
it.  And  yet  no  evacuator  hitherto 
devised,  whether  with  a  long  or  a 
short  connection  between  the  bulb 
and  the  catheter,  accomplishes 
this  important  end ;  they  all  in- 
ject fragments  from  the  apparatus 
back  into  the  bladder.  I  find 
by  experiment  that  a  few  added 
inches  of  elastic  tube  make  little 
i^— —  jL^zaiifTs-  "I  difference;  it  is  from  the  hull  or 
I^^^^^^BIt  I     hottle   that  fragments   are   chiefly 

returned  before  they  settle  into  the 
receiver,  and  not  from  the  tubes. 

To  prevent  this  I  have  fixed  a 
simple  contrivance  to  the  head  of 
the  catheter,  which  is  absolutely 
effectual  in  securing  ever\-  frag- 
ment as  it  comes  through  it  (Fig  2).  It  consists  of  a  small, 
light  glass  cylinder,  containing  a  ball-valve  of  rubber  acting 
noiselessly,  the  valve  seat  of  which  is  perforated  so  as  to 
strain  the  return  current  and  to  keep  back  any  fragment  that 


Fig.  2.1 


1  Catheter-valve,  or  strainer.  A  rubber  ball,  acting  as  a  valve,  has  a 
seat  of  perforated  metal,  which  strains  the  vpater.  It  prevents  the 
fragments  which  pass  it  from  returning. 


MODERN  LITHOTRITY. 


299 


])as  once  passed  it.  Such  a  catheter-valve,  or  strainer,  to  which 
I  alkided  in  my  first  paper  (1878),  is,  I  think,  nearly  as  im- 
portant as  the  large  evacuating  catheter  itself,  of  which  it 
may  indeed  be  considered  as  a  part. 

Other  parts  of  the  apparatus  admit  of 
endless  variations  which  are  less  im- 
portant. 

If  to  the  essential  large  catheter  and 
trap  we  merely  attach  a  strong  elastic 
bulb,  we  have  an  excellent  and  simple  in- 
strument for  a  short  washing  or  for  sound- 
ing for  a  last  fragment.  I  have  called 
this  an  evacuating  sound  (Fig.  3).  No 
fragment  drawn  by  it  from  the  bladder 
can  get  back.  This  apparatus  resem- 
bles Clover's,  which  was  the  first  of  the 
straight  variety.  It  differs  from  it  in 
having  a  large  catheter,  a  valve  or 
strainer,  and  a  stiff  bulb,  all  of  which 
are  either  necessary  or  important  to 
success. 

One  of  the  early  additions  to  my  own 
first  instrument  with  which,  in  its  origi- 
nal form,  Thomas  Smith  successfully 
evacuated  nearly  two  thousand  grains 
of  debris,  was  a  hose.     This  contributes 

greatly  to  the  convenience  of  the  operation.  When,  for  ex- 
ample, at  each  aspiration  of  the  bulb  the  wall  of  the  bladder 
is  drawn  with  a  painful  jerk,  or  series  of  jerks,  into  the  orifice 
of  the  catheter,  evacuation  is  obstructed.  More  water  is  then 
needed  to  distend  the  walls.  This  is  conveniently  supplied  by 
a  small  hose  attached  to  the  top  of  the  bulb  (Figs.  4,  6,  7). 

^  The   evacuating   sound.     It    consists  of   an   evacuating   catheter,  a 
catheter-valve,  and  a  rubber  bulb. 


Fig.  3.1 


300 


MODERN  LITHOTRITY. 


Should  the  patient  strain  or  vomit,  and  the  bladder  be  forci- 
bly distended  in  consequence,  we  have  here  a  means  whereby 
the  superfluous  water  can  be  quickly  removed  from  it.  When 
air  rises  to  the  top  of  the  apparatus  from  the  empty  catheter 
or  a  leaky  joint,  it  can  escape  by  this  hose  and  be  replaced  by 
water.  Valves  in  the  hose  itself,  or  in  the  vessel  into  which 
it  delivers,  allow  the  bloody  water  to  be  changed  for  fresh. 
By  its  means  the  amount  of  water  can  be  regulated,  and  the 
operation  becomes  a  dry  one,  while  the  apparatus  is  as  simple 
as  a  common  enema-syringe. 


Fig.  4.1 


I  have  made  a  convenient  straight  evacuator  out  of  the 
evacuating  sound  by  attaching  to  it  a  light  receiver  (like  that 
of  a  breast  pump)  close  to  the  catheter,  adding  also  a  flat 


1  A  straight  evacuator,  made  from  the  evacuating  sound  by  adding 
below  the  valve  a  glass  receiver  to  hold  the  fragments,  and  above  the  bulb 
a  tap  for  the  hose.  Between  the  valve  and  the  bulb,  inside,  is  a  flat 
strainer  (not  seen)  to  keep  the  fragments  out  of  the  bulb. 


MODEKN  LITHOTRITY. 


301 


strainer  ^  at  the  entrance  of  the  bulb,  to  keep  the  frag- 
ments out  of  it,  and  a  hose  to  manage  the  air  and  water 
(Fig.  4). 

The  same  arrangement  is  here  also 
shown  (Fig.  5)  in  metal  instead  of 
glass. 

In  Fig.  6  the  glass  receiver  has  been 
transferred  from  the  neighborhood  of 
the  catheter  to  the  position  it  occu- 
pied in  my  first  evacuator,  below  the  ^^^  5  2 
bulb,  to  which  the  fragments  are 
now  of  course  admitted,  by  removing  the  fiat  strainer. 


IT  V 


Fig.  6.3 


1  The  strainer,  new  in  the  evacuator,  is  susceptible  of  a  variety  of 
applications  and  of  forms.  A  long  narrow  slit  in  the  tube  answers  as 
well  as  the  perforations. 

2  The  valve  and  trap  of  Fig.  4,  made  of  metal. 

8  The  same  as  Fig.  4,  except  that  the  receiver  is  here  transferred  to 
the  bulb,  and  the  flat  strainer  has  been  removed  to  admit  the  fragments 
to  it. 


302  MODERN  LITHOTRITY. 

All  these  are  varieties  of  the  straight  apparatus.  This  is 
much  the  best,  in  the  distribution  of  its  parts,  of  the  evacua- 
tors  wholly  supported  by  the  hand.  The  centre  of  the  bulb  is 
in  line  with  the  catheter ;  and  were  it  not  so  heavy  when  full 
of  water,  it  would  be  a  most  convenient  handle  for  the  manage- 
ment of  that  instrument.^ 

In  short,  if  the  operator  prefers  to  carry  the  bulb  unsup- 
ported in  his  hand,  straight  instruments,  such  as  have  been 
described,  are  the  best. 

But  1  prefer  a  support  or  stand  of  some  sort.  If  a  flexible 
tube  or  joint  is  interposed  between  the  bulb  and  the  catheter, 
the  former  can  be  supported  upon  the  patient,  or  on  a  stand 
at  a  height  corresponding  with  tlie  inclination  which  the  pros- 
tate gland  gives  the  catheter,  while  the  latter  has  a  free  and 
independent  motion.  Such  is  the  instrument  I  use  for  any 
considerable  evacuation.^ 

It  is  no  great  matter  where  the  catheter  enters  the  wall  of 
the  bulb ;  but  it  should  finally  deliver  inside  at  some  point 
lower  than  the  top,  so  that  any  air  can  rise  out  of  the  way. 
Mr.  Berkeley  Hill  was  quite  right  in  saying  that  the  cathe- 
ter should  not  deliver  into  a  narrow  part  of  the  apparatus 

^  By  a  straight  Instrument  is  here  meant  one  in  which  the  catheter 
and  bulb  are  fixed  in  line  rigidly,  so  that  one  cannot  move  without  the 
other.  If  the  bulb,  still  retaining  a  metal  connection,  were  bent  down 
out  of  this  line,  it  could  be  supported  on  the  patient  or  the  table.  But 
when  it  is  bent  up  and  attached  inflexibly,  it  seems  to  me  more  difficult 
to  manage.  It  is  then  neither  so  convenient  for  the  operator  to  support 
its  weight,  nor  is  it  easy  to  keep  the  catheter  fi'om  oscillating.  The  rigid 
short  connection  seems  to  have  been  adopted  in  the  hope,  by  shortening 
their  route,  of  preventing  a  return  of  fragments.  It  fails  to  do  this,  be- 
cause most  of  the  fragments  come,  not  from  the  tube,  but  from  the  bulb. 

"^  The  mobility  of  the  bull)  in  a  stand  can  be  provided  for  in  a  variety 
of  ways,  —  by  making  a  ball-and-socket  joint  of  the  spherical  bulb  and  a 
ring  (Fig.  7),  or  of  its  glass  receptacle  (Transactions  of  the  Clinical 
Society,  London,  1879,  and  Boston  Medical  and  Surgical  Journal,  January 
1,  1880.  See  pp.  277  and  285  of  this  volume.)  The  bulb  can  also  be 
hung  from  a  crane. 


MODERN  LITHOTRITY. 


303 


where  fragments  are  crowded  together,  because  then  they 
go  back  to  the  bladder.  Tt  is  the  worst  place,  although  if  a 
valve  or  strainer  is  used  the  defect  is  less  important. 


I^IG.  7.1 


But  let  me  repeat  it:  a  proper  tube  to  deliver  the  frag- 
ments, with  an  effectual  contrivance  to  prevent  their  return, 
are  the  essential  parts  of  the  new  apparatus ;  what  remains  is 
a  matter  of  convenience  or  perfection,  and  every  operator  can 
choose  the  arrangement  which  suits  him  best.  When  the. 
instrument  is  imperfect,  the  fragments  will  go  backward  and 
forivard ;  hut  they  always  leave  a  certain  number  outside. 
The  evacuation  will  be  accomplished  in  the  end  by  every  evac- 
uator  that  has  the  large  catheter,  which  is  the  key  to  modern 
lithotrity. 

1  A  complete  evacuator,  used  by  the  writer,  —  being  the  same  as  that 
represented  in  Fig.  5,  with  the  addition  of  a  stand  and  an  elastic  tube. 
Curves  in  the  elastic  tube  make  it  less  liable  to  flatten  when  bent.  The 
hose  is  attached  whenever  it  is  needed. 


304 


MODEKN  LITHOTRITY. 


What  has  here  been  said  about  the  evacuator,  an  instru- 
ment which  has  been  of  late  years  so  modified  as  to  make  it  a 
chief  factor  in  the  operation  of  litliotritj,  is  intended  rather 
to  illustrate  the  principles  which  should  guide  the  surgeon  in 
its  construction  than  to  recommend  any  particular  one.  For 
although  the  instruments  I  showed  at  the  Congress,  and 
which  I  have  described  here,  and  use,  accomplish  the  work  of 

drawing  out  the  fragments 
and  preventing  their  return 
more  perfectly  than  any 
previous  apparatus  for  the 
purpose,  this  is  not  the  only 
consideration  which  in  prac- 
tice determines  the  surgeon 
in  the  choice  of  such  an  in- 
strument. 

I  now  recommend  an 
evacuator  on  the  ground  of 
simplicity  in  construction 
and  economy  in  price.^  It 
works  quite  well  enough, 
witli  or  without  a  stand. 
It  is,  in  fact,  the  instru- 
ment already  described,  with  a  strainer  substituted  for  the 
valve.  Several  instruments  shown  by  me  were  provided  with 
strainers,  but  this  one  is  arranged  with  reference  to  the  fact 


Fig.  8.2 


1  The  aspirators  here  described,  and  also  the  various  lithotrites,  are 
made  by  J.  Weiss  and  Son,  London. 

■■^  The  "  Simplified  Evacuator  "  and  Stand.  The  catheter  is  prolonged, 
by  a  long  tubular  strainer,  into  the  bulb.  This  makes  a  catheter-valve, 
though  still  advantageous,  less  necessary.  An  elastic  ball  or  universal 
joint,  with  a  small  tubular  strainer,  is  also  substituted  at  the  head  of  the 
catheter  for  the  elastic  tube,  and  makes  the  instrument  shorter.  The 
stand  is  here  a  retort  stand.  The  bulb  hangs  firmly  in  a  fork  (separately 
figured),  and  can  be  variously  inclined. 


MODERN  LITHOTRITY.  305 

that  the  return  of  fragments  from  the  apparatus  to  the  bladder 
is  much  greater  from  the  bulb  than  from  the  tubes,  to  which 
it  has  been  erroneously  attributed.  The  strainer  is  here  a 
perforated  cylinder  added  to  the  catheter,  passing  inside  the 
bulb  and  extending  nearly  across  it.  Through  this  the  frag- 
ments are  drawn  into  the  bulb-cavity.  They  swirl  there  for  a 
few  seconds  ;  but  when  the  water  goes  back  to  the  bladder,  it 
strains  them  off,  and  they  fall  into  a  receiver.  The  length- 
ened tube  adds  little  to  the  amount  of  the  returned  debris,  and 
if  obstructed  is  easily  cleared  by  a  rod  (Fig.  11).  The  appa- 
ratus here  described  has  the  following  advantages  :  — 

1.  As  the  bulb  is  spherical,  whether  a  receiver  is  attached 
to  it  or  not,  the  hand  of  the  operator,  grasping  its  centre,  is 
in  line  with  the  catheter  as  if  holding  the  handle  of  a  long 
screw-driver,  —  which  is  better  than  if  the  hand  were  above  it, 
out  of  line.  This  is  an  advantage  common  to  all  straight 
evacuators. 

2.  The  instrument  is  a  short  one.  A  long  inflexible  appa- 
ratus is  liable  to  irregular  movements,  which  produce  pain. 
Otherwise,  the  tubular  strainer  might  be  placed  outside  the 
bulb  (in  the  glass  trap,  for  example,  described  by  Mr.  Berke- 
ley Hill,  Figs.  9,  10).  It  is  here  fixed  inside  the  bulb  (Figs. 
8,  11),  which  so  shortens  the  apparatus  that  we  have  room 
for  two  connecting  cocks,  one  for  the  bulb  and  one  for  the 
catheter.  This  makes  the  operation  much  drier  than  where 
there  is  no  cock  for  the  catheter. 

3.  There  is  a  hose  for  air  and  water  above  the  bulb,  and  a 
receiver  for  fragments  below  it. 

Without  a  stand,  this  instrument  belongs  to  the  straight 
evacuators,  with  a  rigid  connection  between  the  catheter  and 
bulb.  The  operator  then,  of  course,  supports  the  weight  of 
the  bulb,  which  I  find  troublesome  if  the  operation  is  more 
serious  than  that  of  washing  out  the  bladder  or  securing  a  last 
fragment.     We  can  easily  have  a  stand  here,  steady  enough 

20 


306 


MODERN  LITHOTRITY. 


Fig.  10. 


to  sustain  the  weight  of  the  arm  of  the  operator,  and  prevent 
the  oscillation  of  the  catheter.  Three  inches  of  elastic  tube, 
or  an  elastic  ball  about  an  inch  in  diameter,  can  be  interposed 

between  the  bulb  and  catheter  to  act 
as  a  universal  joint. ^  It  is  then  easy 
to  rest  the  bulb  in  one  hand  on  the 
patient's  thigh,  while  the  catheter  is 
manipulated  with  the  other,  or  upon 
the  glass  receiver  flattened  into  a 
foot.  The  stand  here  figured  is  of 
simple  construction,  and  can  be  ad- 
justed at  any  convenient  height  with 
reference  to  the  catheter  (see  Pig.  8).^ 
I  have  condensed  the  arrangement 
here  described  from  the  materials  re- 
ferred to  in  the  preceding  part  of  this 
paper,  having  been  lately  persuaded 
that  a  compact  and  inexpensive  ap- 
paratus, performing  as  perfectly  as  this  one,  is  a  desider- 
atum. To  designate  it  appropriately,  I  have  called  it  "  The 
Simplified  Evacuator."  A  stand  and  elastic  joint  can  be  had 
with  it. 


Fig.  11. 


Within  three  years  renewed  attention  has  been  given  to  the 
lithotrite,  which  was  supposed  to  be  beyond  improvement.     A 

1  A  small  metal  drum  with  elastic  ends  makes  a  good  joint.  The 
metal  sides  cannot  fall  against  the  catheter  and  obstruct  it. 

2  Figs.  9,  10,  and  11,  —  diagrams  intended  to  show  how  much  a  straight 
instrument  (Fig.  9)  is  shortened  by  flattening  the  glass  receiver  (Fig.  10) 
or  by  removing  it  from  the  catheter  (Figs.  4,  5,  9,  10)  to  the  bulb  (Figs. 
6,  7,  8,  11).  The  space  may  be  occupied  by  stop-cocks  (Fig.  11).  The 
body  of  the  bulb  is  spherical,  and  lies  in  the  axis  of  the  catheter,  with  a 
hose  and  a  receiver  attached  to  it. 

3  If  the  patient  lies  on  a  soft  bed,  the  bulb  must  be  held  in  the  hand, 
unless  the  stand  be  steadied,  like  a  fracture  box,  by  something  under  it. 
But  I  usually  do  this  surgical  operation,  like  others,  on  a  table  of  some  sort. 


MODERN  LITHOTRITY.  307 

calculus  may  indeed  be  crushed  by  any  lithotrite,  if  strong 
enough ;  but  since  decisive  crushing  has  become  more  desir- 
able, and  the  limit  to  the  size  of  the  stone  has  been  extended, 
different  lithotrites  are  more  and  more  used  for  different 
stones.  The  old  lithotrite,  the  combined  work  of  Retore,  Cos- 
tello,  Charriere,  and  Weiss,  underwent  little  change  in  half  a 
century.  A  most  convenient  addition  to  it  is  the  long  handle 
described  by  Thompson.^  It  gives  a  better  hold  for  the  left 
hand.  But  the  inconvenient  button  in  the  lock  of  Weiss, 
which  it  incloses,  has  never  been  changed.  The  thumb  and 
the  eye  of  the  operator  must  search  for  it  when  the  instru- 
ment is  turned.  By  changing  the  lock  a  little  I  have  been 
able  to  replace  this  button  by  a  more  convenient  ring,  which 
the  fingers  cannot  miss  (Fig.  12),  To  reach  this  ring-lock 
with  the  fingers,  after  the  stone  is  seized,  requires  neither 
practice  nor  attention,  while  one  or  both  are  needed  with  the 
Weiss  button. 


Fig.  12.2 

The  easiest  movement  of  the  right  forearm  or  hand  is  rota- 
tion from  left  to  right,  —  supination.  I  have  adapted  the 
locking  of  my  lithotrite  to  this  motion.^  An  instrument  which 
can  be  thus  locked  and  unlocked  has  this  superiority,  that  not 
even  the  fingers  of  either  hand  relax  their  grasp  until  the 
stone  has  been  screwed  down  between  the  blades.     No  other 

1  Practical  Lithotomy  and  Lithotrity,  p.  157.     London,  1863, 

2  A  lithotrite  in  which  a  ring  is  substituted  for  Weiss's  button  to 
operate  the  lock. 

3  This  was  accomplished  by  making  the  usual  guides,  which  prevent 
the  screw  from  rattling  against  the  sides  of  the  lock,  also  turn  and  close 
it,  by  the  action  of  the  right  hand  upon  the  male  blade.  I  have  called  it 
the  male-blade  lock. 


308 


MODERN  LITHOTRITY. 


lithotrite  gives  the  surgeon  this  advantage.  This  lock  is  at- 
tached to  the  usual  American  instrument,  and  I  have  lately 
further  improved  it  (Figs.  13  and  14). 


Fig.  13.1 


Fig.  14. 

We  may  educate  the  movements  of  the  hand  to  the  piano, 
the  violin,  or  some  especial  lithotrite,  but  the  process  is  labori- 
ous. That  instrument,  therefore,  is  the  most  convenient,  which, 
in  accomplishing  its  object,  is  best  adjusted  to  the  readiest 
movements  of  the  hand.  Workmen  may  become,  indeed,  pro- 
ficient in  the  use  of  any  form  of  instrument ;  but  the  skill  of 
the  Japanese  wood  or  metal  worker,  which  is  unrivalled,  is 
not  evidence  of  the  convenience  of  his  tools,  which  are  rude. 

In  the  "Lancet"  of  Nov.  2,  1878,  p.  616,  I  pointed  out 
the  advantages  of  certain  lesser  modifications  of  the  usually 
accepted  lithotrite,  partly  new  and  partly  not.  Among  these 
were,  besides  the  increased  calibre  of  the  jaws,  a  large  open- 
ing at  the  heel  of  the  female  blade  into  which  the  flanges  of 
the  male  blade  projected  so  as  to  drive  out  the  debris  and  pre- 
vent impaction  where  it  is  likely  to  be  greatest ;  jaws  as  much 
at  right  angles  with  the  stem  as  can  be  safely  introduced, 
whereby  their  efficacy  is  increased ;  a  thicker  toe  to  the  female 


1  Figs.  13  and  14,  —  author'.s  lithotrite,  having  a  male-blade  or  right- 
hand  lock,  which  is  closed  by  a  quarter  revolution  of  the  lock  cover  held 
between  the  thumb  and  fore-finger  of  the  operator's  right  hand.  It  also 
has  an  elongated  vulcanite  handle  shaped  to  fit  the  hand. 


MODERN  LITHOTRITY.  309 

blade,  elongated  to  prevent  the  bladder  from  being  seized  by 
the  closing  blades,  and  well  rounded  off  to  facilitate  its  in- 
troduction ;  a  ball,  or  larger  wheel  or  handle  instead  of  the 
classical  narrow  wheel  of  Civiale,  which  had  been  retained  for 
half  a  century  although  it  excoriates  the  hands  (see  Figs.  13, 
14, 15,  16).  The  adoption  of  all  these  changes  in  the  most 
common  American  lithotrite,  and  their  recent  valuable  in- 
dorsement, in  his  later  instrument,  by  so  skilful  a  lithotritist 
as  Sir  Henry  Thompson,  show  their  value. 

Before  choosing  the  instruments  for  an  operation,  I  measure 
both  the  urethra  and  the  stone.  But  the  limit  to  the  size  of 
instruments  is  not  merely  mechanical ;  it  is  also  related  to 
the  fact  that  the  membranous  urethra  is  peculiarly  intolerant 
of  injury. 

The  healthy  urethra,  according  to  Otis,  has  a  calibre  about 
32  French,  the  meatus  being  about  24.  I  generally  use  a 
catheter  about  29  French  (18  English),  but  also  smaller  sizes, 
which  are  often  more  comfortable  to  the  unetherized  patient, 
and  in  a  diseased  subject  safer.  With  25  or  26  you  can  pro- 
duce the  click  of  a  last  fragment  or  of  a  small  calculus,  and 
easily  deliver  it  when  crushed.  In  fact,  much  of  the  debris 
of  a  stone  is  in  the  form  of  dust,  and  what  is  not  can  be 
further  comminuted. 

But  when  the  stone  is  not  a  small  one,  and  the  urethra  is 
of  normal  capacity,  I  use  the  size  29  or  30,  or  even  31,  —  as 
large  as  the  urethra  will  comfortably  admit,  but  no  larger. 
The  advantage  in  doing  so  is  that  the  smaller  fragments  need 
not  be  crushed  again. 

Strong  lithotrites  are  now  in  general  use  for  large  and  hard 
stones.  I  like  a  large  lithotrite  on  account  of  its  powerful, 
rapid,  and  efficient  action ;  but  it  by  no  means  follows  that  it 
is  essential  to  use  a  large  instrument  to  break  a  small  stone. 
Any  small  lithotrite  answers  for  small  stones.  The  average 
stone  of  these  days  is  small.     I  always  crush  a  last  fragment 


310  MODERN  LITHOTRITY. 

with  a  small  instrument.  A  large  stone  once  broken  can  ob- 
viously be  treated  by  an  instrument  of  less  size ;  but  once  in 
the  bladder,  I  think  the  surgeon  will  generally  continue  to 
use  the  instrument  with  which  he  has  successfully  begun  the 
crushing. 

A  calculus  out  of  the  bladder  would  be  crushed  best  by  a 
colossal  instrument  at  a  single  grasp.  It  is  the  necessity  of 
safely  introducing  and  withdrawing  the  instrument  that  deter- 
mines the  size  of  its  blades.  The  length  has  most  to  do  with 
their  introduction ;  the  calibre  at  the  heel,  with  their  with- 
drawal through  the  prostatic  and  membranous  urethra. 

While  long  blades  slide  easily  from  the  meatus  as  far  as  the 
triangular  ligament,  the  delicacy  and  skill  of  a  practised  oper- 
ator are  needed  at  this  part  of  the  passage.  On  the  other 
hand,  once  safely  in  a  bladder  of  fair  size,  a  long  blade  has  a 
positive  advantage  in  seizing  and  crushing  the  stone.  The 
instrument  can  be  readily  turned  down  either  way  upon  the 
oval  floor,  especially  if  the  handle  be  inclined  a  little  to  the 
side  toward  which  the  blades  are  turned.  Behind  the  per- 
pendicular wall  of  a  high  prostate,  short  and  blunted  blades 
which  can  be  inverted  readily  are  the  most  convenient. 

The  calibre  of  the  blades  is  a  question  by  itself.  Blades 
may  safely  be  large  at  the  heel,  which  is  the  largest  part,  if 
they  do  not  become  clogged  with  debris,  and  by  their  in- 
creased size  endanger  the  neck  of  the  bladder  while  being 
withdrawn.  If  they  cannot  be  cleared  of  debris  they  should 
be  small.  Fergusson's  method  of  removing  debris  with  the 
lithotrite  is  not  now  generally  in  use.  No  lithotrite  that  can  be 
cleared  is  drawn  out  loaded.  It  is  almost  universally  agreed 
that  fragments  can  be  removed  better  through  a  catheter 
than  in  a  lithotrite.  This  fact  has  led  to  renewed  search  for 
a  lithotrite  that  can  be  completely  emptied  and  closed  be- 
fore withdrawal,  without  danger  of  impaction.  It  can  then 
be  made  stronger  and  larger, —  at  least  as  large  as  a  smaller 


MODERN  LITHOTRITY. 


311 


lithotrite  when  it  is  full  of  debris,  or  as  the  evacuating  cathe- 
ter (26  to  29  French)  that  is  used  at  the  same  time,  —  and 
since  it  does  not  need  to  be  I'epeatedly  withdrawn  to  be  emp- 
tied, crushing  can  be  continued  as  long  as  it  is  desirable. 

The  dust  of  certain  stones  mixed  with  mucus  clogs  the 
lithotrite,  especially  at  the  heel,  with  a  very  hard  composition. 
To  prevent  this,  I  have  recommended  a  high  floor  at  this  part, 
or,  what  is  the  same  thing,  low  sides  in  the  female  blade ;  and 
in  the  male  blade,  lateral  notches  steep  enough  to  push  off  the 
ddbris  laterally  CFigs.  15  and  16).     This  plan  has  been  adopted 


Fig.  15.1 


Fig.  16. 


in  the  more  common  American  instrument.  I  also  think 
well  of  the  fenestrated  lithotrite  in  practised  hands.  An 
instrument  of  this  kind  will  comminute  the  stone,  especially 
a  hard  one,  sufficiently  to  pass  the  catheters.  When  lithot- 
ritists,  three  years  ago,  were  warning  one  another  against  the 


1  Figs.  15  and  16, — blades  of  the  author's  lithotrite.  The  notches,  as 
here  represented,  are  intended  to  be  deep  and  steep  enough  to  insure  the 
blades  against  the  usual  impaction  in  front-  At  the  heel,  where  clog- 
ging is  always  worst,  the  debris,  divided  by  the  spur  of  the  male  blade, 
falls  off  on  each  side  from  the  high  floor  of  the  female  blade.  The  female 
blade  has  a  long  blunted  toe,  curved  forward.  The  size  of  the  heel  is  26 
French. 


312 


MODERN  LITHOTRITY. 


danger  of  fatal  cystitis,  —  which  had  been  attested,  as  they 
supposed,  by  the  experience  of  half  a  century,  —  my  first  pre- 
caution while  making  experiments  was  to  protect  the  floor  of 
the  bladder  by  a  solid  female  blade.  A  projecting  splinter  of 
stone,  firmly  set  in  the  fenestra  of  an  open  female  blade, 
while  being  crowded  through  it,  is  obviously  a  dangerous 
weapon.  The  blades  should  always  be  lifted  off  the  floor  as 
soon  as  the  fragment  is  secured,  before  crushing  it.  But  it 
is  a  great  relief  to  the  hand  of  the  operator  if  the  blades  shut, 
at  the  last  moment,  quietly  together.  The  old  fenestrated 
instrument  can  be  made  to  crush  as  well  as  cut  the  stone  by 
widening  the  female  blade  and  sharpening  its  rim  inside  so 
as  to  retain  it  (Fig.  17).     This  also  protects  the   bladder 


Fig.  17.1 


Fig.  18.2 


from  any  scissors-like  action  of  the  edges.  The  sole  of  the 
male  blade  is  grooved  lengthwise,  and  serrated.  In  order  to 
widen  the  hold  upon  the  stone  in  another  way  and  occupy 
less  room  in  the  urethra,  I  have  used  a  zigzag  fenestrated 

1  Fenestrated  instrument,  with  a  wide  floor  and  high  rim  to  hold  the 
stone  while  being  crushed.     The  toe  is  long  and  curved. 

2  Fenestrated  instrument,  with  blades  curved  laterally  to  widen  the 
grasp  upon  the  calculus.     The  toe  is  also  curved. 


MODERN  LITHOTRITY.  313 

blade,  which  has  proved  quite  efficient  (Fig.  18).  I  have 
employed  a  fenestrated  instrument  with  great  success  upon 
a  hard  stone,  which  it  crushes  and  does  not  slice  as  it  does 
a  soft  stone.  Dr.  Keyes  first  advocated  the  use  of  the  fenes- 
trated instrument  to  avoid  impaction  in  the  long  sitting. 

The  toe  of  the  female  blade  should  be  not  only  long  and 
rounded,  so  that  it  shall  not  injure  the  upper  wall  of  the 
prostatic  urethra  as  it  moves  along,  but  I  have  also  curved  it 


Fig.  19.1 

forward.     Its  added  length,  besides  protecting  the  bladder, 
then  makes  the  passage  easier  (Figs.  15,  16,  17,  18,  and  19). 

Let  me  add  a  few  general  remarks.  Lithotrites  are  of  sev- 
eral sizes,  and  of  two  sorts, — the  solid  and  the  fenestrated. 
The  latter  of  course  cannot  clog,  and  has  been  sufficiently 
described.  Of  the  former  it  may  be  further  said  that  it  does 
not  clog,  the  notches  in  the  male  blade  being  steep  enough  to 
deliver  the  detritus  at  the  side.  It  is  absolutely  essential 
that  the  notches  be  deep  and  well  slanted.  This  implies  a 
thick  male  blade,  to  which  I  have  no  objection.  The  crush- 
ing is  chiefly  done  at  the  front  of  the  blades,  where,  so  far  as 
I  know,  every  other  lithotrite  with  solid  blades  clogs.     The 

1  Diagram  intended  to  show  how  the  curved  and  blunted  toe  protects 
the  roof  of  the  membranous  urethra,  and  also  that  the  blades  in  passing 
occupy  no  more  room  with  it  than  without  it.  The  position  of  the  instru- 
ment here  represented  is  the  proper  one  at  this  part  of  the  urethra.  The 
dotted  line  shows  that  the  curve  is  the  result  of  removing  superfluous 
metal  from  the  sole  of  a  blunted  blade. 


314  MODERN  LITHOTRITY. 

heel,  Avhich  never  crushes  advantageously,  has  here  a  long 
narrow  fenestra,  cleared  by  a  projecting  metal  plate  which 
passes  through  it.  This  divides  the  debris,  one  half  of  which 
falls  off  at  each  side  from  the  high  floor,  and  effectually 
hinders  clogging  where  it  is  always  worst.  These  litho- 
trites  have  the  male-blade  lock  and  long  vulcanite  handle 
figured  in  the  previous  pages.  The  blades  represented  in 
Figs.  15  and  16  are  of  the  middle  size.  They  measure  at  the 
largest  part  of  the  heel  26  French.  The  stem  of  the  in- 
strument is  small,  and  moves  freely  in  the  urethra,  but  it 
communicates  great  power  to  the  blades,  which  are  strong, 
and  adapted  to  general  use. 

A  straight  catheter,  which  I  think  evacuates  best,  generally 
passes  with  great  ease.  Sometimes  a  curved  catheter  passes 
better,  and  now  and  then  the  urethra  is  capricious  about 
receiving  any  instrument.  In  passing  an  instrument,  after 
dividing  the  meatus  if  necessary,  or  divulsing  a  stricture, 
we  reach  at  once  the  triangular  ligament,  where  the  chief 
difficulty  of  the  passage  lies.  Here  the  instrument  should  be 
insinuated  with  a  light  hand,  not  by  depressing  the  handle  in 
a  quarter  circle  as  if  it  were  a  catheter,  still  less  by  force ; 
but  the  aperture  should  be  carefully  sought  for.  Beginners 
are  very  apt  to  strike  above  it.  To  avoid  this  mistake,  after 
the  instrument  has  been  passed  vertically  down  quite  as  far 
as  it  ivill  go^  it  should  be  withdrawn  a  little  before  being 
pushed  forward,  and  this  manoBuvre  repeated  till  the  point 
slides  through  the  ligament.  A  surgeon  may  quickly  acquire 
great  skill  in  passing  an  instrument  in  the  living  urethra,  by 
practice  upon  the  dead  subject,  if  he  will  twist  a  common  tin 
sound  into  irregular  angles  and  curves,  and  pass  first  one  end 
and  then  the  other  through  this  opening.  The  ligamentous 
orifice  is  really  the  turning  point  in  the  successful  passage  of 
an  instrument.  Once  safely  beyond  it,  a  catheter,  if  straight, 
can  be  rotated  horizontally  through   the   prostatic   urethra. 


MODERN   LITHOTRITY.  315 

But  a  curved  catheter,  or  a  lithotrite,  should  be  lowered  only 
to  an  angle  of  about  45°  with  the  horizon,  if  the  patient  is 
on  his  back,  and  then  urged  carefully  forward  like  a  boat  in 
the  water  upon  an  even  keel.  The  floor  of  the  canal  is  de- 
pressed by  the  heel  of  the  instrument  as  it  slides  along,  and 
this  relieves  its  roof  from  the  pressure  of  the  toe  (Fig.  19). 

I  usually  search  for  a  stone  with  a  common  tin  sound  bent 
extemporaneously  to  suit  the  case,  and  measure  it  with  a  litho- 
trite, which  also  makes  an  excellent  sound.  The  search  for  a 
last  fragment  or  a  minute  calculus  is  best  done  with  a  small 
evacuating  catheter  by  which  the  fragment  can  escape,  or, 
if  too  large  to  pass,  is  arrested  with  an  audible  click.  A 
trap  and  bulb  are  attached  to  it  (see  Fig  3).  In  these 
days  fragments  are  made  to  seek  the  sound  rather  than 
the  sound  the  fragments,  as  has  been  the  case  heretofore. 
I  think  that  the  old  method  of  sounding  for  a  small  calcu- 
lus is  generally  abandoned,  unless  the  calculous  material  is 
adherent  or  otherwise  immovable. 

Evacuation  is  a  simple  thing,  and  is  usually  successful, 
even  with  an  imperfect  evacuator.  To  secure  the  water  I  tie 
an  elastic  band  round  the  penis  after  the  catheter  is  in  place, 
and  judge  of  the  distension  of  the  bladder  by  ascertaining, 
from  time  to  time,  the  tension  of  tlie  urethra  behind  it.  The 
pumping  is  an  easy,  continuous  movement.  There  is  no  need 
of  pausing  after  the  stroke,  wliich  may  be  as  rhythmical  as 
the  swing  of  a  pendulum.  If  any  pause  is  made,  it  is  after 
compressing  the  bulb,  to  let  the  debris  settle,  when  there  are 
few  left.  Every  fragment  sooner  or  later  finds  the  catheter, 
most  of  them  at  once  and  with  surprising  readiness.  The 
most  advantageous  spot,  higher  at  first,  lower  when  fragments 
become  fewer,  is  soon  discovered  by  trial.  A  quarter  of  an 
inch  higher  or  lower  sometimes  makes  an  unexpected  differ- 
ence. When  the  fragments  cease  to  fall  into  the  receiver, 
the   catheter   may  be  immediately  withdrawn ;   but   I    often 


316  MODERN  LITHOTRITY. 

add  to  the  evacuation  a  thorough  sounding  in  pursuit  of  a 
possible  last  fragment,  which  perhaps  does  not  exist,  and 
thereby  make  the  operation  much  longer.  This  search  can 
be  deferred  if  the  condition  of  the  patient  makes  it  desirable, 
although  I  do  not  think  it  more  important  to  abbreviate  this 
surgical  operation  than  any  other.  Without  this  prolonged 
attempt  at  complete  evacuation,  verified  by  a  final  careful 
sounding,  evacuation  is  usually  a  short  matter ;  and  the 
number  of  grains  evacuated  in  a  unit  of  time,  say  in  a 
minute,  is  large. 

Let  me  illustrate  with  a  single  case  how  the  catheter  may 
be  obstructed.  A  patient  was  relieved  three  years  ago,  by 
lithotomy,  of  about  a  gill  and  a  half  of  stones  of  the  uniform 
size  of  small  marbles.  A  month  ago  I  operated  upon  him 
by  crushing.  The  operation  occupied  two  and  a  half  hours, 
and  was  tedious  in  the  extreme.  Neither  the  lithotrite  nor 
the  evacuator  performed  as  usual.  Afterward  it  was  clear 
that  the  crushing  was  slow  because  I  could  never  seize  a 
piece  larger  than  a  marble ;  and  evacuation  was  next  to  im- 
possible, because  the  catheter  was  constantly  obstructed  by  a 
similar  marble.  The  patient  did  well.  He  was  seventy-two 
years  old.  The  quantity  removed  was  nearly  nine  hundred 
grains. 

Among  diseases  that  obviously  reduce  the  chances  of  a 
patient,  surgical  kidney,  upon  which  Sir  Henry  Thompson 
has  laid  much  stress,  is  perhaps  the  most  common  and  most 
fatal  complication  of  any  operation  for  stone.  Its  symptoms 
have  been  of  late  so  accurately  defined  by  Professor  Guyon 
and  his  disciple.  Dr.  Bazy,  that  perhaps  the  most  important 
single  question  to  be  solved,  if  possible  before  operating,  is 
whether  the  patient  has  surgical  kidney  or  not. 

I  adopt  no  special  preparatory  treatment.  If  necessary, 
immediately  before  the  operation,  I  enlarge  the  meatus  or 
divulse  a  stricture.     Rest  after  a  journey,  the  relief  of  some 


MODERN  LITHOTRITV.  317 

obviously  aggravated  and  temporary  symptom,  the  antiseptic 
or  other  washing  of  the  bladder  when  desirable,  —  all  this 
belongs  to  the  common  principles  and  common  practice  of 
surgery. 

After  the  operation,  opiates  and  warm  fomentations  are 
often  comforting  and  sometimes  essential.  The  bladder 
should  be  left  empty,  and  as  far  as  possible  kept  so.  Where 
complete  retention  is  probable,  and  it  is  always  possible, 
the  patient  should  be  within  reach  of  the  surgeon.  The 
bladder  may  be  washed  out  with  water  or  mild  antiseptic 
fluid,  if  the  character  of  the  urine  suggests  it.  One  of  the 
most  troublesome  complications  is  a  mass  of  mucus  that 
creates  tenesmus,  and  will  not  pass  through  the  catheter. 

I  have  been  cognizant  of  four  fatal  cases  in  which  the 
deep  urethra,  which  is  less  tolerant  of  injury  than  the  blad- 
der, was  lacerated.  Such  cases  do  not  count  against  litliot- 
rity,  but  show  the  need  of  habit  as  well  as  care  in  passing 
and  withdrawing  the  instruments,  especially  the  larger  sizes. 
These,  in  the  hands  of  the  general  surgeon,  are  less  safe  than 
the  smaller  ones.  Within  the  bladder  the  entire  wall  can 
hardly  be  caught  with  impunity  in  the  forceps-like  extremities 
of  the  old  lithotrite,  though  strips  of  mucous  membrane  have 
been  torn  from  it  without  serious  consequences. 

I  think  I  am  justified  in  assuming  it  to  have  been  demon- 
strated that  where  lithotrity  has  hitherto  been  the  accepted 
rule  of  practice,  as  in  the  case  of  a  healthy  patient  or  of  a 
small  stone,  the  new  method  is  better  tban  the  old  one,  and 
that  the  domain  of  lithotrity  has  been  notably  extended.  I 
think  we  need  no  further  statistics  relating  to  small  stones. 

The  question  still  remaining  concerns  lithotomy  and  its 
indications.  It  is  whether  modern  lithotrity  is  not  better 
than  lithotomy  in  that  class  of  cases  hitherto  claimed  by 
lithotomy,  comprising  larger  stones  and  surgical  kidneys, 
conditions  which  are  distinctly  unfavorable  to  any  operation 


318  MODERN  LITHOTRITY. 

at  all.  It  will  take  time  to  decide  this  point.  The  practised 
surgeon  may  even  find  it  so  difficult  to  rid  himself  of  a  merely 
traditionary  preference  for  lithotomy  that  the  verdict  may 
be  unnecessarily  delayed.  But  even  when  lithotomy  is  suc- 
cessful, I  ask  myself  if  the  patient  would  not  have  encoun- 
tered a  less  risk  with  the  new  lithotrity?  I  do  not  know  any 
new  indications  that  enable  us  to  decide  peremptorily  when 
lithotomy  is  better  than  lithotrity.  The  latter  does  not,  it  is 
true,  so  completely  drain  and  rest  the  bladder.  In  the  case 
of  a  large  stone  it  is  perhaps  likely  to  be  done  less  skilfully 
than  the  operation  of  lithotomy  by  the  general  surgeon.  But 
there  is  no  danger  of  secondary  haemorrhage,  nor  is  there  a 
grave  wound  in  a  diseased  prostate,  communicating  perhaps 
with  a  putrid  catarrh  of  the  urinary  tract.  As  yet  no  dis- 
proportionately unfavorable  results  have  set  a  limit  to  the 
new  lithotrity  for  large  calculi  and  diseased  patients.  On 
the  contrary,  its  use  is  becoming  more  common.  Extraor- 
dinary stones  have  been  successfully  removed  by  crushing. 

I  myself  add  to  twenty-one  cases  I  have  already  published 
of  promiscuous  stones,  large  and  small,  twenty-four  other  cases 
with  one  death.  Of  these  I  mention  here  only  ten  cases,  — 
comprising  six  calculi  weighing  over  two  hundred  grains  and 
under  five  hundred,  one  over  five  hundred  and  under  seven 
■hundred,  and  three  over  seven  hundred  and  under  one  thou- 
sand grains.  The  single  death  was  by  septic  infection,  in  a 
patient  sixty-six  years  of  age,  having  a  phosphatic  stone  of 
two  hundred  and  seventy  grains.  There  was  no  apparent 
injury  of  the  canal  or  bladder  sufficing  to  explain  it.  The 
only  peculiarity  of  the  case  was  an  unusual  vascularity  of  the 
urethra  during  the  operation. 

The  manoeuvres  in  a  long  sitting  do  not  greatly  differ  from 
those  in  a  short  one  ;  but  they  need  more  persistent  care 
and  patience,  because  the  attention  is  rather  apt  to  flag  during 
the  continued  repetition  of  the  same  movements.  The  pos- 
session   of  a  reflex    skill,    acquired  by   practice    and   acting 


MODERN  LITHOTRITY.  319 

without  thought,  as  in  swimming,  bicycling,  writing,  or  play- 
ing a  musical  instrument,  is  then  of  the  greatest  value.  It 
insures  to  the  patient,  as  no  mere  good  intention  can,  the 
advantage  of  what  Cadge  has  called  "  all  the  little  knacks  and 
tricks  which  go  to  make  up  successful  lithotrity."  I  think, 
with  the  improvements  here  shown,  the  operation  becomes 
safer  for  the  general  surgeon.  I  often  hear  of  successful 
operations  upon  large  stones  by  the  new  method  in  the  hands 
of  surgeons  who  have  scarcely  done  lithotrity  before ;  but  I 
am  satisfied  that  patients  are  yet  safer  in  the  hands  of  a 
surgeon  who  makes  lithotrity  in  some  measure  a  special 
study. 


520  LITHOLAPAXY. 


LITHOLAPAXY. 

REMARKS   MADE   AT    A    MEETING   OF   THE   BOSTON    SOCIETY   FOR 
MEDICAL   IMPROVEMENT.! 

Dr.  Bigelow,  in  opening  the  discussion,  said  he  had  been 
much  interested  in  the  cases  reported.  Dr.  Cheever's  case 
was  that  of  a  hard  stone,  while  Dr.  Gay's  was  that  of  a  large 
one.  The  results  which  they  had  obtained  might  be  expected 
as  a  rule. 

In  reply  to  the  inquiry  how  often  it  was  necessary  to  slit 
the  meatus,  Dr.  Bigelow  said  that  the  necessity  was  only  ex- 
ceptional. If  the  meatus  is  small,  and  the  operation  is  to  be 
along  one,  it  is  a  convenient  and  harmless  expedient;  it  is 
well  to  take  a  little  care  afterward  not  to  engage  the  mucous 
edge  of  the  urethra  upon  the  catheter  and  strip  it  up. 

Air  in  the  bladder  does  no  harm.  The  amount  contained 
in  the  catheter  is  legitimately  there ;  beyond  this  amount  no 
air  can  enter  the  apparatus  unless  from  leaky  joints.  A  little 
air  is  often  as  comfortably  trapped  for  a  time  in  the  top  of  a 
large  bladder  as  in  the  evacuator.  The  only  harm  the  air 
does  is  to  take  up  room  which  is  better  occupied  by  water  if 
the  bladder  is  not  a  capacious  one.  It  is  easy  to  remove  it 
from  the  evacuator  through  a  stop-cock  and  small  hose  at  the 
top  of  the  bulb,  through  which  also  the  amount  of  water  can 
be  regulated. 

Asked  how  long  cystitis  lasted  after  the  operation,  Dr.  Big- 
elow replied  that  it  depended  on  the  relation  it  bore  to  the 
stone  ;  that  is,  if  the  stone  were  the  disease,  and  the  cystitis 
were  dependent  on  its  presence,  it  would  be  cured.  If,  on  the 
other  hand,  there  were  a  previous  cystitis  with  enlarged  pros- 

1  The  Boston  Medical  and  Surgical  Journal,  March  23,  1882. 


LITHOLAPAXY.  321 

tate,  and  the  stone  were  the  result  of  these  conditions,  the 
relief,  though  often  considerable,  would  be  partial.  Cystitis 
with  a  large  secretion  of  mucus  is  a  troublesome  complication. 
The  mucus  plugs  the  urethral  orifice,  causing  painful  tenes- 
mus until  the  tenacious  mucus  comes  away  in  a  mass,  and  the 
bladder  is  relieved. 

In  answer  to  further  inquiries,  Dr.  Bigelow  said  that  perhaps 
the  most  difficult  part  of  the  crushing  operation  is  picking  up 
pieces  behind  the  vertical  wall  of  certain  forms  of  enlarged 
prostate.  As  a  rule  the  stone  is  easiest  secured  by  pressing 
down  the  floor  of  the  bladder  with  the  heel  of  the  lithotrite, 
which  then  occupies  a  pocket  into  which  the  stone  gravitates ; 
or  by  carrying  the  instrument  well  back,  opening  it,  turning 
it  to  one  or  the  other  side,  and  closing  it.  A  stone  or  frag- 
ment behind  the  prostate  can  be  usually  caught  by  depressing 
the  floor  beyond  it ;  although  if  the  perpendicular  wall  of  the 
prostate  is  high  it  may  be  difficult  to  reach  it  even  by  invert- 
ing a  short  blade.  One  difficulty  with  the  old  lithotrite  was 
the  obliquity  of  the  heel,  so  that  when  the  crushing  force  is 
applied  the  stone  is  urged  forward  in  the  blades.  The  clear- 
ing out  of  an  obstruction  in  the  straight  tube  can  easily  be 
accomplished  by  passing  through  it  an  ordinary  tin  sound. 
A  curved  tube  sometimes  gives  more  trouble,  but  can  be  freed 
by  an  elastic  catheter.  Any  resistance,  however  slight,  in 
withdrawing  the  tube  should  lead  the  operator  to  suspect  that 
a  dangerously  large  fragment  is  engaged  in  its  extremity. 

In  reply  to  a  question  as  to  whether  he  had  ever  known 
injury  to  result  from  nipping  the  walls  of  the  bladder,  Dr. 
Bigelow  said  that  he  knew  of  one  case  in  which  he  believed 
a  fatal  issue  was  due  to  that  accident.  In  the  ordinary  in- 
strument, with  blades  fitted  at  their  extremities  as  accurately 
as  forceps  are,  and  with  a  female  blade  having  no  projection 
to  keep  away  the  wall  of  the  bladder,  the  latter  must  often  be 
seized.     If  only  the  mucous  membrane  were  torn,  no  serious 

21 


322  LITHOLAPAXY. 

effect  might  ensue ;  but  if,  in  a  thin  bladder,  the  whole  thick- 
ness of  the  walls  were  pinched,  he  thought  there  must  be 
danger.  For  this  reason  he  himself  felt  easier  in  using  his 
own  instrument,  which  guards  against  this  accident.  The 
long  female  blade  is  especially  useful  to  those  not  operating 
habitually. 

In  regard  to  the  choice  of  a  straight  or  curved  tube.  Dr. 
Bigelow  thought  neither  was  safer ;  the  danger  depends  on 
the  relation  in  size  between  the  catheter  and  urethra.  The 
tube,  if  large,  must  be  introduced  with  great  care  and  with  a 
perfect  understanding  of  the  anatomy  of  the  parts,  directing 
it  downward  until  it  reaches  the  layer  of  fat  lying  between  the 
urethra  and  the  rectum,  then  coaxing  it  through  the  aperture 
in  the  triangular  ligament,  and  finally  reaching  the  bladder 
by  a  corkscrew  motion  of  the  straight  tube  in  the  axis  of  the 
body.  In  only  two  or  three  cases  had  Dr.  Bigelow  found  any 
trouble  in  introducing  a  straight  tube.  Sometimes  the  curved 
tube  can  be  easiest  introduced  by  hugging  the  pubes,  and  thus 
passing  the  upper  instead  of  the  lower  part  of  the  opening  in 
the  triangular  ligament.  The  introduction  of  the  straight  tube 
is  usually  easier  to  the  surgeon,  but  perhaps  not  quite  so  com- 
fortable to  the  unetherized  patient.  After  the  curved  tube 
has  entered  the  bladder  the  shaft  occupies  the  urethra,  and 
is  of  course  straight. 

Aided  by  the  blackboard,  Dr.  Bigelow  described  at  some 
length  the  difficulties  of  attaining  a  perfect  and  convenient 
evacuator,  and  explained  the  faults  of  all  those  now  in  use. 
The  question  is  one  of  physics,  and  involves  the  separation  of 
air,  water,  and  fragments  in  the  most  effectual  way  by  the 
simplest  means.  He  believed  that  he  had  at  last  devised  a 
satisfactory  instrument.  To  suppose  that  experiments  to  this 
end,  out  of  the  bladder,  have  no  value,  is  like  supposing  that 
the  edge  of  a  surgical  knife  can  be  tested  only  on  the  living 
tissues. 


LITHOTRITY,  WITH  EVACUATION.  323 


LITHOTRITY,  WITH   EVACUATION. 

REMARKS   MADE   AT   A    MEETING    OF   THE    NEW  YORK   ACADEMY 
OF  MEDICINE.^ 

Dr.  Bigelow  said  that  when  asked  some  time  ago  by  the 
president  to  present  this  subject  before  the  Academy,  he  felt 
that  it  was  one  which  had  ah'eady  become  old,  and  so  familiar 
to  most  surgeons  that  he  could  offer  but  little  of  interest  in 
connection  with  it ;  and  it  was  only  when  the  request  was 
again  urged,  at  a  subsequent  time,  that  he  had  reluctantly 
consented  to  do  so.  He  believed,  however,  that  his  own  ac- 
cumulated experience,  and  especially  that  of  the  New  York 
surgeons,  had  now  thrown  added  light  upon  the  operation. 
He  could  not  forget  also  that  it  was  in  New  York  that  the 
procedure  which  he  had  labored  to  perfect  had  received  its 
first  distinct  approbation,  and  that  at  a  time  when  it  needed 
friends.  The  profession  here  had  then  tested  the  matter  by 
practical  experiments  ;  and  he  could  not  refrain  from  men- 
tioning his  special  obligation  to  the  distinguished  Professor 
Van  Buren,  among  others,  for  his  interest  and  assistance. 

The  subject,  he  continued,  was  one  relating  distinctly  to 
operative  surgery,  a  mechanical  one ;  and  it  was  to  the  me- 
chanical part  of  it  —  a  mere  matter  of  physics  —  that  what- 
ever advances  had  been  made  in  lithotrity  of  late  were  really 
due.  He  should  confine  himself  therefore,  during  the  limited 
time  at  his  disposal,  to  the  mechanical  procedure,  because  he 
believed  it  was  what  the  Academy  would  perhaps  prefer  now 
to  discuss.  There  were  a  number  of  points  in  regard  to  which 
he  would  like  to  have  an  expression  of  opinion  from  some  of 

1  The  Boston  Medical  and  Surgical  Journal,  May  25,  1882. 


324  LITHOTRITY,   WITH   EVACUATION. 

the  gentlemen  present.  Any  common  lithotrite,  he  went  on 
to  say,  would  break  a  stone,  and  most  evacuators  will  re- 
move it ;  but  it  was  an  important  question  which  special 
instrument  would  do  it  best.  Although  it  was  stated  by  Sir 
James  Paget  and  other  authorities,  during  the  noted  discus- 
sions which  took  place  in  London  in  1878,  that  the  subject  of 
lithotrity  had  apparently  gone  as  far  as  it  could  go,  and  that 
the  operation  would  probably  not  be  further  improved,  yet 
since  that  time  all  the  lithotritists  had  been  steadily  at  work, 
and  distinct  advances  had  been  made.  It  was  desirable  at 
the  present  day  to  use  instruments  materially  different  from 
those  formerly  in  use,  although  the  whole  question  was  still 
one  of  breaking  up  a  stone  and  getting  the  fragments  out 
through  the  urethra,  —  an  operation  that  had  been  in  vogue 
for  many  years. 

When  Civiale  began  to  operate  he  required  from  twenty 
to  thirty  minutes ;  but  as  he  improved  his  instruments  he 
gradually  reduced  the  time  to  three  or  four  minutes,  —  a 
limit  to  the  sitting  generally  accepted  and  taught  since 
Civiale's  day. 

The  means  for  removing  the  fragments  completely,  however, 
did  not  formerly  exist.  The  sharp  fragments  remained  in  the 
bladder  and  did  the  damage,  not  the  operation.  When  it  came 
to  be  possible  to  remove  them,  it  was  found,  to  the  surprise  of 
everybody,  that  the  bladder  was  a  very  tolerant  organ.  That 
this  tolerance  of  the  bladder  had  never  been  suspected  up  to 
that  time,  and  the  fact  tliat  such  an  error  had  existed  for  half 
a  century,  seemed  to  show  the  advantage  of  doubting  every- 
thing in  medicine  of  which  we  had  had  no  personal  experience. 
The  single  agent  to  which  actual  progress  was  due  was  the 
large  catheter  which  held  the  urethra  open  while  the  frag- 
ments were  drawn  out  through  it ;  and  it  was  a  fact  that  the 
small  catheter  of  Clover's  instrument  had  retarded  progress 
for  a  very  long  time.     In  1846,  Sir  Philip  Crampton  had 


LITHOTRITY,   WITH  EVACUATION.  325 

drawn  out  a  large  quantity  of  debris  in  the  form  of  powder 
by  means  of  a  vacuum  made  in  a  glass  globe.  If  fragments 
were  completely  pulverized,  of  course  a  small  catheter  would 
answer  for  the  removal  of  the  whole  calculus  ;  but  the  blad- 
der could  not  afford  to  wait  until  pulverization  was  gradually 
accomplished. 

A  large  catheter  by  itself  was  not  a  new  device,  since  it  had 
been  in  use  in  former  times  to  some  extent.  Collin's  instru- 
ment had  a  catheter  of  number  25  or  26 ;  but  it  was  found  to 
be  inefficient,  and  was  soon  pronounced  impracticable.  The 
distinctly  new  and  important  point  in  the  apparatus  now  em- 
ployed was  the  use  of  a  large  catheter  —  25  to  31  —  in  combi- 
nation with  an  efficient  suction.  This  constituted  the  novelty 
of  the  thing.  Having,  then,  the  large  catheter,  the  first 
question  was.  Should  it  be  straight  or  curved  ?  This  was  a 
matter  concerning  merely  the  introduction  of  the  instru- 
ment ;  'and  Dr.  Bigelow  said  that  he  preferred  a  straight 
one.  As  most  of  the  passage  was  practically  straight,  it 
could  be  introduced  with  greater  facility  than  a  curved  one. 
The  choice  was  simply  one  of  convenience,  and  was  related 
to  the  habit  of  the  operator,  or  sometimes  to  the  individual 
case. 

Dr.  Bigelow  next  described  the  character  of  the  extremity  of 
the  catheter  which  he  preferred,  and  drew  a  diagram  of  it  upon 
the  blackboard.  It  was  oblique  and  blunted,  and  had  a  pro- 
jecting lip  of  considerable  length  below,  while  the  orifice  was 
above.  The  orifice,  he  said,  should  be  about  the  size  of  the 
calibre  of  the  tube,  for  if  it  were  larger  than  this  a  fragment 
was  liable  to  become  engaged  there  ;  and  in  this  connection  he 
mentioned  a  death  which  occurred  in  consequence  of  the  ori- 
fice of  the  catheter  em})loyed  being  disproportionately  large. 
A  fragment  had  thus  become  fixed ;  and  as  a  result  of  the 
laceration  of  the  urethra  occasioned  in  its  withdrawal  the 
patient  died  of  septicaemia.     Dr.  Bigelow  also  recommended 


326  LITHOTRITY,   WITH   EVACUATION. 

that  the  tube-wall  above  the  orifice  should  be  thickened,  so 
that  no  injury  might  be  inflicted  by  its  edge. 

The  next  point  involved  the  important  matter  of  retaining 
the  fragments  when  they  had  been  once  withdrawn  from  the 
bladder.  It  was  a  curious  fact  that  until  now  all  evacuators, 
so  far  as  he  knew,  returned  to  the  bladder  something  like 
one  third  to  one  half  of  all  fragments  evacuated.  This  had 
been  attributed  to  the  length  of  the  elastic  tube  sometimes 
employed ;  but  the  length  of  the  tube  was  not  the  main  diffi- 
culty. As  a  fact,  it  was  found  on  investigation  that  the  frag- 
ments were  really  returned  from  the  bulb,  and  that  a  little 
additional  prolongation  of  the  tube  made  very  slight  difference. 
Nevertheless  he  had  tried  to  devise  a  trap  at  the  extremity  of 
the  tube.  It  consisted  of  a  little  glass  cylinder  containing 
a  valve  in  the  shape  of  a  loose  rubber  ball,  which  worked 
backward  and  forward,  and  thus  closed  and  opened  the  ori- 
fice alternately,  while  the  water  returned  through  a  strainer. 
This  he  had  found  to  work  very  well ;  but  as  the  objection 
had  been  made  that  it  was  too  complicated  an  arrangement, 
he  had  afterward  employed  a  simpler  one,  which  also  acted 
perfectly,  and  which  he  had  not  as  yet  published.  This  was 
nothing  more  or  less  than  half  an  inch  of  cotton  tube  fast- 
ened at  the  end  of  the  metal  tube,  in  such  a  way  that  it 
acted  as  a  valve  in  closing  and  opening  the  orifice.  Still, 
as  even  this  might  be  thought  complicated  by  some  surgeons, 
he  had  tried  quite  a  number  of  other  valves.  An  objec- 
tion to  a  metal  valve  was  that  it  was  liable  to  become  ob- 
structed by  fragments.  Consequently  he  had  been  obliged  to 
resort  to  a  variety  of  expedients,  which  he  would  refer  to  in  a 
moment. 

He  would  first  go  a  step  further,  and  speak  of  the  evacuator 
as  a  whole.  We  are  to  dispose  by  means  of  it  of  air,  water, 
and  fragments.  The  receptacle  for  the  fragments  might  be 
placed  either  between  the  catheter  and  the  bulb  or  below  the 


LITHOTRITY,   WITH   EVACUATION.  327 

bulb  itself.  For  his  own  part,  Dr.  Bigelow  considered  it 
better  to  place  the  receptacle  immediately  below  the  bulb, 
especially  for  the  reason  that  it  materially  shortened  the  in- 
strument ;  and  this  of  itself  was  a  very  important  advantage. 
It  was  also  an  important  matter  to  place  the  axis  of  the  bulb 
in  a  line  with  the  axis  of  the  catheter ;  otherwise  there  would 
be  a  leverage  causing  the  instrument  to  work  at  a  great  dis- 
advantage. The  moment  the  bulb  and  the  receptacle  were 
combined  in  one  piece  the  question  arose  whether  or  not  the 
catheter  should  be  detached  by  an  elastic  tube  to  allow  its 
freer  motion.  The  ordinary  straight  elastic  tube  was  liable 
to  double  on  itself,  and  thus  obstruct  the  flow  of  water ;  but 
a  curved  tube  of  proper  construction  was  not  open  to  this 
objection.  In  regard  to  the  use  of  a  stand.  Dr.  Bigelow  said 
that  his  preferences  had  been  in  favor  of  it.  Perhaps  his 
present  opinion  might  be  best  expressed  in  this  way :  if  the 
stone  were  a  small  one,  and  the  operation  short,  it  was  better 
to  dispense  with  the  stand ;  but  if  it  were  large,  the  stand  was 
a  considerable  help,  since  the  two  or  three  pounds'  weight  of 
the  instrument  made  quite  a  difference  to  the  operator  if  it 
had  to  be  supported  by  the  hand.  Still,  the  general  belief  in 
such  matters  was  often  the  correct  one,  and  the  prevailing 
practice,  which  was  opposed  to  the  use  of  the  stand,  he  was 
willing  to  adopt. 

Dr.  Bigelow  then  exhibited  the  first  instrument  which  he  em- 
ployed, and  remarked  that  it  made  no  sort  of  difference  at  what 
point  the  catheter  entered  the  bulb,  provided  it  did  not  finally 
deliver  directly  at  the  top  where  the  air  collects.  If  the  tube 
penetrated  even  for  a  short  distance  into  the  bulb  from  above, 
an  air  chamber  was  at  once  formed.  The  only  air  that  belonged 
legitimately  in  the  bulb  was  that  which  came  from  the  cathe- 
ter, and  the  amount  of  air  varied  with  the  calibre  of  the 
catheter.  The  best  rule  was  to  have  the  catheter  deliver  as 
near  the  centre  of  the  bulb  as  possible  ;  and  when  this  was  the 


328  LITHOTRITY,   WITH  EVACUATION. 

case,  the  greatest  possible  facility  was  afforded  for  the  uninter- 
rupted passage  of  the  fragments  into  the  receptacle  below. 
If  the  tube  entered  the  lower  narrow  part  of  the  bulb  where 
the  fragments  accumulated,  it  was  important  that  it  should  be 
prolonged  above  this  point,  or  else  they  would  be  returned  in 
great  quantity  to  the  bladder.  This  brought  him  to  the  point 
of  showing  how  regurgitation  of  the  fragments  from  the  bulb 
took  place  in  almost  all  instruments.  He  then  exhibited  an 
evacuator  which  he  said  had  been  abandoned  by  its  author,  and 
beneath  the  bulb  of  which  he  had  attached  a  short  glass  tube 
so  that  the  course  of  the  currents  might  be  observed.  It  was 
clearly  demonstrated  that  a  considerable  portion  of  the  frag- 
ments went  directly  back  into  the  bladder.  How  then,  it 
might  be  asked,  was  evacuation  ever  accomplished  by  such  an 
instrument?  Simply  by  washing  the  fragments  backward 
and  forward  between  the  bladder  and  the  instrument  until  all 
of  them  had  been  finally  dropped  into  the  receptacle.  This 
has  been,  till  now,  a  serious  defect  of  many  evacuators. 
There  was  in  this  instrument  also  a  current,  which  actually 
lifted  the  fragments  out  of  the  glass  receptacle  and  sent 
them  back  to  the  bladder.  In  other  words,  the  general  fact 
held  good,  that  wherever  tlie  water  goes  in  an  evacuator  the 
fragments  go  also,  unless  they  are  prevented  by  means  of 
a  strainer. 

Dr.  Bigelow  exhibited  the  latest  instrument  devised  by 
Weiss,  of  London,  which  he  had  received  during  the  past 
winter,  and  remarked  that  the  first  difficulty  about  it  was 
that,  as  in  Clover's  evacuator,  the  bulb  was  not  stiff  enough. 
In  his  own  instruments,  a  special  point  was  made  of  having  the 
bulb  sufficiently  stiff.  A  second  difficulty  was  that  some  of  the 
fragments,  following  as  usual  the  course  of  the  current,  were 
collected  in  the  bulb  and  thence  carried  back  into  the  bladder. 
Dr.  Bigelow  also  exhibited  one  of  his  own  instruments  with 
a  valve,  which  worked  perfectly  well,  although  he  said  that  it 


LITHOTRITY,  WITH  EVACUATION.  329 

was  not  as  simple  in  construction  as  was  desirable.  It  was 
provided  with  a  stand.  He  had  often  felt  it  a  relief  to  stop 
once  in  a  while  in  a  long  operation  to  see  how  things  were 
going  on,  which  the  self-supporting  character  of  the  instrument 
enabled  him  to  do  with  ease.  With  regard  to  the  rubber  hose 
which  was  attached  to  the  top  of  the  bulb  and  provided  with 
a  stop-cock,  he  regarded  the  device  as  a  great  advantage,  and 
had  continued  to  employ  it  in  all  his  evacuators  up  to  the  pres- 
ent time.  Its  purpose  was  not  only  to  dispose  of  the  air,  but 
especially  to  add  or  remove  water.  As  had  been  stated,  the 
only  air  legitimately  held  in  the  bulb  was  that  contained  in 
the  catheter.  If  it  were  desirable  to  get  rid  of  even  this 
amount  of  air,  it  could  be  promptly  accomplished  by  com- 
pressing the  bulb  and  filling  its  place  with  water  by  means 
of  the  hose.  Another  point  in  this  connection  was,  that  all 
bladders  were  not  of  the  same  size  or  the  same  elasticity.  In 
a  small  bladder  it  was  difficult  to  evacuate  completely  because 
the  walls  were  liable  to  fall  against  the  catheter.  This  was 
owing  to  the  fact  that  there  was  not  enough  water  in  the 
bladder.  It  could  easily  be  added  by  means  of  the  hose,  and 
the  quantity  graduated  exactly  according  to  the  desire  of  the 
operator.  Sometimes  during  the  operation  the  patient  strained 
or  vomited,  so  that  everything  became  very  tense  ;  and  in  that 
case  we  had  only  to  open  both  stop-cocks  and  deliver  the  water 
temporarily.  He  believed,  therefore,  that  the  hose  was  a  valu- 
able addition,  both  for  the  purpose  of  getting  rid  of  air  and  of 
regulating  the  amount  of  water  according  to  the  circumstances 
arising  from  time  to  time  during  the  operation. 

Finally,  Dr.  Bigelow  exhibited  the  new  and  simple  instru- 
ment which  he  said  he  had  now  settled  down  upon,  and  which 
could  be  used  with  either  a  single  stop-cock  or  with  two,  as 
might  be  preferred.  In  the  first  place,  it  had  a  spherical  bulb 
acting  as  a  handle  in  the  axis  of  the  catheter.  In  the  second 
place,  it  was  quite  short  from  end  to  end.     In  the  third  place. 


330  LITHOTRITY,  WITH  EVACUATION. 

the  obliquity  of  the  tube  carried  the  receptacle  high  in  the  air, 
one  advantage  of  which  was  that  it  brought  it  nearer  the  level 
of  the  eye  of  the  surgeon.  In  the  fourth  place,  the  whole 
thing  fitted  well  into  the  cavity  of  the  hand  which  held  it. 
In  regard  to  the  use  of  stop-cocks,  he  preferred  to  have  two 
instead  of  a  single  one.  He  then  gave  a  demonstration  of  its 
manner  of  working,  —  it  being  shown,  after  a  moment  or  two, 
that  there  was  not  a  fragment  left  remaining  in  the  glass 
vessel  used  to  represent  the  bladder.  The  simple  method  by 
which  this  desirable  result  was  accomplished,  he  said,  could 
readily  be  understood.  There  was  a  cylindrical  strainer  that 
prolonged  the  catheter  inside  the  bulb ;  and  inasmuch  as  any 
strainer  may  get  clogged  with  fibrin,  resulting  from  an  in- 
flamed state  of  the  bladder,  this  was  so  arranged  that  it  could 
be  readily  removed  and  cleaned  by  brushing.  The  strainer 
could  be  replaced  in  an  instant.  The  fragments  enter  the 
bulb"  from  the  bladder  through  the  main  orifice,  by  reason  of 
the  momentum  which  the  current  has  acquired  in  coming 
from  the  bladder.  But  the  combined  area  of  the  small  aper- 
tures along  the  tube  being  much  larger  than  that  of  the 
principal  orifice  at  its  extremity,  most  of  the  water  returns 
by  these  apertures,  and  is  strained. 

Dr.  Bigelow  then  spoke  briefly  in  regard  to  the  lithotrite. 
He  stated  that  the  most  convenient  instrument  of  any  sort 
was  that  which  was  best  adapted  to  the  movements  of  the 
hand.  In  devising  his  own  instrument,  therefore,  he  had 
first  considered  which  was  the  easiest  motion  of  the  latter, 
and  had  arrived  at  the  conclusion  that  this  was  its  rotation. 
He  had,  therefore,  not  only  made  the  handle  of  a  size  adapted 
to  the  hand,  but  so  that  it  could  be  worked  by  rotation.  He 
had  also  provided  the  lithotrite  with  a  lock,  by  means  of  which 
any  position  of  the  blades  could  be  maintained  as  long  as 
desired,  without  the  necessity  of  changing  the  position  of  the 
hand.     The  blades  were  made  at  as  near  a  right  angle  as 


LITHOTRITY,   WITH   EVACUATION.  331 

would  admit  of  their  introduction  into  the  bladder  with  con- 
venience and  safety,  and  are  thus  found  to  work  at  a  much 
greater  advantage  than  the  more  oblique  blades  formerly 
sometimes  employed.  As  the  greatest  impaction  always  took 
place  at  the  heel  of  the  instrument,  he  had  abandoned  the 
idea  of  crushing  much  at  this  point,  and  passed  a  flange 
through  it,  in  order  to  bisect  the  detritus  and  discharge  it 
laterally.  The  crushing  was  mainly  done  in  front  of  the 
heel.  When  the  patient  was  in  good  health,  he  believed 
that  the  safety  of  the  procedure  depended  simply  upon  the 
surgeon's  skill ;  and  that  with  the  facilities  now  at  our  com- 
mand, if  proper  care  were  observed,  there  would  very  rarely 
be  any  bad  consequences.  In  cases  where  the  kidneys  were 
affected,  however,  favorable  results  were  not,  of  course,  always 
to  be  anticipated. 


o32  A   SIMPLIFIED   EVACUATOR. 


A   SIMPLIFIED   EVACUATOR  FOR  LITHOLAPAXY.i 

The  operation  for  the  immediate  removal  of  a  calculus 
through  a  catheter,  like  many  other  surgical  operations,  can 
be  accomplished  more  or  less  satisfactorily  by  any  one  of  sev- 
eral instruments  which  much  resemble  one  another.  But  it 
can  be  done  better  by  employing  a  more  perfect  apparatus 
than  those  now  generally  in  use.  It  has  been  said  that  "  no 
new  form  of  instrument  is  required  by  this  operation,"  which 
is  true  so  far  as  it  implies  that  neither  a  lithotrite  nor  an 
evacuator  is  a  new  instrument.  But  it  would  be  a  mistake 
to  infer  that  the  operation  could  have  been  done  with  the 
instruments  of  the  old  lithotrity,  and  that  they  needed  no 
change  to  adapt  them  to  what  is  now  required  of  them,  or 
that  they  cannot  be  still  further  modified  to  advantage.  The 
new  operation  cannot  be  performed  with  the  old  instruments. 
It  requires  a  larger  evacuating  catheter  than  that  of  Clover, 
through  which  the  usual  product  of  the  lithotrite  could  not 
pass,  except  as  powder  and  sand,  and  then  only  in  limited 
quantities,  because  the  other  detritus  obstructed  the  entrance 
of  the  tube.2     Though  at  first  received  with  a  good  deal  of 

1  The  Lancet,  January  6  and  13,  1883. 

2  Sir  Henry  Thompson  says  (Diseases  of  the  Urinary  Organs,  Phila- 
delphia and  London,  1882):  "The  evacuating  catheter  to  be  attached  to 
the  aspirator  should  be  as  large  as  the  urethra  will  admit ;  usually  No.  15 
or  16  of  the  English  scale  [26  to  28^  French]  may  be  used  without  any 
danger.  Sometimes  No.  17  or  18  [30  and  31  French]  are  admissible ;  but 
such  sizes  are  quite  unnecessary  for  small  stones,  and  may  produce  mis- 
chief ;  hence  they  are  only  to  be  used  where  the  presence  of  a  large  stone 
demands  corresponding  instruments."  Or,  it  might  be  added,  to  expedite 
the  operation,  when  the  urethra  is  large  and  healthy.  The  size  of  the 
normal  urethra,  according  to  Otis,  is,  if  we  except  the  meatus,  32  of  the 
French  scale.     Clover's  evacuating  catheter  was  21.     Those  now  in  use 


A   SIMPLIFIED   EVACUATOR.  333 

distrust,  the  large  catheter  has  been  finally  adopted  by  all  the 
surgeons  who  have  performed  the  operation,  and  in  fact  cannot 
be  dispensed  with.  It  should  be  combined  with  a  thoroughly 
efficient  aspirator.  But  no  particular  form  of  aspirator  has 
so  far  met  with  general  approval.  Though  improvement  has 
been  made,  surgeons  have  no  aspirator  which  entirely  satis- 
fies all  requirements  of  tlie  operation,  and  is  at  the  same  time 
compact  and  convenient  to  handle  and  simple  in  construction. 
This  part  of  the  evacuator  still  needs  improvement. 

The  usual  parts  of  an  evacuator,  not  including  the  catheter, 
are  these  :  — 

1.  The  exhaust,  the  best  form  of  which  is  an  elastic  bulb. 

2.  A  space  or  trap  for  air,  at  the  upper  part  of  the  instru- 
ment. 

3.  A  glass  receiver  at  the  lower  part,  to  collect  and  show 
the  debris. 

In  drawing  out  fragments  from  the  bladder  through  the 
large  catheter,  one  bulb  or  aspirator,  if  strong  enough,  is 
about  as  efficient  as  another.  An  aspirator  of  almost  any 
shape  and  having  almost  any  combination  of  its  parts  will 
do  this.  So  will  a  mere  elastic  bulb  attached  directly  to 
the  catheter,  without  joints  or  receiver,  if  it  is  placed  lower 

range  from  26  to  3] .  Care,  however,  and  often  special  skill  may  be  re- 
quired to  introduce  safely  the  largest  sizes ;  31  is  very  rarely  needed,  and 
the  French  sizes  28  and  29  are  generally  the  most  convenient.  For  a 
final  washing  or  sounding  without  ansesthesia,  when  it  is  desirable  to  give 
the  patient  the  least  discomfort,  even  so  small  a  calibre  as  26  is  some- 
times useful.  Through  a  catheter  of  this  calibre  Mr.  Teevan  has  removed 
calculi  weighing  six  or  eight  hundred  grains ;  but  such  cases  should  be 
regarded  as  showing  what  is  possible,  rather  than  as  establishing  a  rule 
of  practice.  Here  I  may  add  that  although  no  lithotrite  compares  in  size 
with  the  larger  tubes,  it  is  yet  true  that  long-bladed  lithotrites,  especially 
if  they  have  the  sharp  extremity  of  the  old  instruments,  are  more  difficult 
than  tubes  to  introduce  with  safety.  Although  since  1878  my  lithotrites 
have  been  made  in  three  sizes,  I  have  rarely  had  occasion  to  employ  any 
other  than  the  middle  size. 


334  A  SIMPLIFIED  EVACUATOR. 

than  the  catheter,  and  bent  down  like  the  body  of  a  retort,  so 
that  the  fragments  can  fall  to  the  bottom  of  it ;  and  the  in- 
strument will  still  work  well  if  it  has  joints  made,  for  economy, 
of  cork  or  rubber  instead  of  metal.  But,  however  otherwise 
arranged,  a  satisfactory  aspirator  should  have  — 

4.  Some  device,  near  the  catheter,  to  act  as  a  trap  for  debris 
and  secure  every  fragment  that  has  passed  it. 

The  chief  difference  among  evacuators  now  is  in  the  degree 
of  certainty  with  which  they  retain  the  fragments  they  have 
aspirated.  Any  instrument  will  draw  out  the  fragments,  but 
few  hold  them  securely ;  for  the  debris  do  not  always  fall  into 
the  glass  receiver,  nor  do  they  always  remain  in  it.  On  the 
contrary,  they  are  easily  carried  back  to  the  bladder.  This 
defect  in  the  action  of  the  evacuator  has  received  little  atten- 
tion from  surgeons,  although  it  is  the  only  point  connected 
with  the  evacuator  which  offers  any  difficulty  whatever.  Until 
recently  it  has  been  remedied  only  by  sacrificing  simplicity  in 
the  apparatus. 

In  endeavoring  to  make  a  satisfactory  evacuator  for  lith- 
olapaxy,  many  experiments  have  to  be  tried.  It  is  quite 
possible  that  a  perfectly  satisfactory  instrument  might  have 
been  contrived  some  time  ago  if  it  had  been  generally  under- 
stood that  an  evacuator  that  works  best  with  pieces  of  broken 
coal  in  a  vessel  of  water  will  succeed  best  with  the  fragments 
in  the  bladder.^  So  also  will  the  surgeon  if  he  is  otherwise 
well  qualified.  It  is  true  that  the  living  tissues  are  easily 
injured,  but  in  other  respects  the  experiment  can  be  made  suf- 
ficiently like  the  operation  to  give  it  great  value.  Aspirating 
debris  from  the  bladder  is  not  a  question  of  pathology,  but  of 
operative  surgery,  —  of  physics ;  and  in  view  of  the  fact  that 
we  fail,  in  some  bladders,  to  discover  a  last  fragment  even  by 
repeated  washing,  an  evacuator  should  be  so  constructed  that 

1  The  specific  gravity  of  hard  coal  is  1.575.  That  of  a  urate  calculus 
is  1.540,  and  of  a  mulberry  calculus,  1.262. 


A  SIMPLIFIED  EVACUATOR.  335 

it  will  absolutely  prevent  a  fragment  that  has  once  passed  the 
catheter  from  returning  to  the  bladder  to  become  the  nucleus 
of  another  calculus. 

It  is  not  altogether  easy  to  meet  this  requirement,  because 
the  solid  particles  are  usually  borne  back  and  forth  with  the 
current  of  water.  In  a  common  evacuator,  they  are  carried 
wherever  the  current  goes,  —  first  from  the  bladder  to  the 
bulb,  and  then,  when  it  is  reversed,  back  to  the  bladder,  a 
part  only  falling  into  the  receiver  at  each  aspiration.  As 
we  may  fairly  assume  that  a  surgeon  would  not  deliberately 
inject  foreign  bodies  into  a  patient's  bladder,  there  must  be 
something  wrong  in  a  system  which  obliges  him  to  do  this, 
and  makes  it  necessary  to  aspirate  the  same  debris  twenty 
times  over  in  order  to  remove  it.  In  short,  the  apparatus  as 
commonly  arranged  is  still  a  defective  one,  and  needs  some 
special  contrivance  to  assist  the  action  of  gravity  in  securing 
the  debris. 

Surgeons  have  long  felt  this.  The  use  of  an  elastic  tube 
connected  with  the  catheter  has  been  more  than  once  criti- 
cised, and  with  some  reason,  on  the  ground  that  it  might 
contain  fragments  which  would  be  returned  to  the  bladder ; 
and  again,  in  order  to  shorten  by  an  inch  the  route  from  the 
bladder,  a  less  convenient  stop-cock  has  been  substituted  for 
the  usual  one.  But  lithotritists  should  be  fully  aware  of  the 
fact  that  whether  there  is  an  elastic  tube  or  not,  a  tenfold 
greater  quantity  of  fragments  is  generally  driven  back  out  of 
the  bulb  itself,  and  that  the  difficulty  lies  almost  wholly  in 
that  part  of  the  instrument.  At  each  expansion  debris  are 
drawn  from  the  bladder  into  the  bulb,  where  they  are  delayed 
until,  when  it  is  compressed,  they  are  injected  back  into  the 
bladder.  Only  a  part  of  them,  sometimes  only  the  larger  half 
(the  quantity  varying  in  different  instruments),  settle  into  the 
glass  receiver.  This  important  fact,  so  little  recognized, 
should  not  be  accepted  without  demonstration. 


336  A  SIMPLIFIED  EVACUATOE. 

An  instrument  which  Sir  Henry  Thompson  has  lately  aban- 
doned (Fig.  1)  can  be  made  to  demonstrate  exactly  how  the 
currents  act  upon  the  fragments,  in  an  evacuator  which  is 
unprovided  with  a  catheter-trap  to  prevent  them  from  re- 
entering the  bladder.  It  is  here  selected  because  the  peculiar 
form  of  this  instrument  makes  it  easy  to  fit  a  glass  tube  to  it 
so  that  we  can  see  what  takes  place  in  the  interior.  Let  a 
piece  of  glass  tube  an  inch  in  diameter  be  inserted  at  the  joint 
JJ^  between  the  bulb  B  and  the  catheter,  to  show  what  passes 
with  the  current  from  one  to  the  other  in  either  direction.  If 
the  end  of  the  catheter  be  now  placed  in  a  suitable  vessel  of 
water  containing  fragments  of  coal  of  different  sizes,  while 
the  bulb  is  alternately  compressed  and  allowed  to  dilate,  a 
continued  stream  of  fragments  will  be  seen  rising  from  the 
vessel  into  the  bulb,  and  then  returning  to  the  vessel,  as  they 
inevitably  would  do  to  the  bladder.  The  back-flow  of  debris 
can  be  still  better  watched  if  a  glass  tube  be  also  substituted 
for  the  catheter,  as  in  the  figure. 

But  there  is  another  important  fact  illustrated  by  this  in- 
strument. Fragments  do  not  always  stay  in  a  receiver  after 
they  have  been  deposited  there.  When  the  glass  receiver  R 
of  this  evacuator  is  half  filled  with  fragments,  a  part  of  these 
are  easily  carried  back  into  the  vessel  or  into  the  bladder. 
They  are  first  lifted  up  from  the  receiver  into  the  bulb,  and 
then  driven  out  through  the  catheter  ;  for  though  the  orifice 
of  this  glass  receiver  is  small  and  protected  by  a  special  trap, 
the  current  and  debris  pass  out  of  it  as  well  as  into  it.  It 
could  not  have  been  foreseen  that  fragments  would  escape 
from  a  receptacle  apparently  so  well  arranged  ;  but  it  will  be 
found  that  in  any  instrument,  if  the  bulb  or  catheter  directs  the 
current  into  the  glass  receiver,  whether  directly  or  obliquely, 
fragments  are  easily  carried  out  again. 

The  general  result  is  little  better,  if,  to  avoid  stirring  the 
fragments  which  lie  in  the  receiver,  the  current  is  directed 


A  SIMPLIFIED   EVACUATOE. 


337 


These  two  figures  illustrate  the  fact 
that  all  evacuators  return  fragments  to 
the  bladder  unless  provided  with  an  ar- 
rangement to  retain  them.  The  joint 
JJ  of  the  smaller  figure  is  opened  in 
the  larger  figure  to  receive  a  glass  tube. 
Through  this,  fragments  are  seen  as  they 
are  drawn  into  the  bulb  and  expelled 
from  it.  The  glass  evacuating  catheter 
shows  them  on  their  way  to  and  from  the 
bladder.   The  receiver  R.  shows  fragments 

in  the  act  of  being  lifted  by  the  current  and  returned  to  the  bladder. 

22 


338  A  SIMPLIFIED  EVACUATOR. 

horizontally  over  the  mouth  of  it  instead  of  into  it.  Some  of 
them  then  pass  directly  back  and  forth  between  the  bladder 
and  the  bulb,  over  the  receiver,  without  falling  into  it.  This  de- 
fect can  be  shown  in  an  instrument  recently  employed  by  Sir 
Henry  at  the  suggestion  of  Weiss  and  Co.,^  where  the  stream 
from  the  catheter  passes  horizontally  through  an  empty 
chamber  on  its  way  to  the  bulb.  As  the  stream  enters  it,  its 
velocity  is  so  diminished  that  fragments  fall  to  the  bottom 
into  the  receiver,  and  in  greater  number  when  the  bulb  is  weak. 
Many  fragments  are  of  course  secured.  But,  to  be  wholly 
effectual,  the  chamber  intended  to  retard  and  break  up  the 
current  by  its  size  would  have  to  be  inconveniently  large,  in 
order  to  give  time  to  the  floating  debris  entering  on  one  side  to 
settle  into  the  receiver  without  passing  farther.  The  principle 
here  involved  is  quite  different  from  that  of  the  evacuator  rep- 
resented in  the  above  figure.  This  instrument  is  not  unlike  one 
formerly  figured  in  the  "  Lancet ; "  ^  but  the  valve  and  strainer 
which  there  act  as  a  trap  have  been  omitted,  and,  in  conse- 
quence, not  a  few  fragments  escape  back  to  the  bladder. 

In  Weiss's  evacuator  again,  some  of  the  fragments  which 
enter  the  bulb  gather  in  the  bottom  of  it,  which  is  lower  than 
its  outlet,  and  where  there  is  no  receiver  to  collect  them. 
The  chief  difficulty,  however,  is  not  that  these  fragments  stray 
into  the  bulb,  but  that  for  want  of  a  trap  they  are  afterward' 
liable  to  escape  out  of  it  and  back  to  the  bladder. 

This  difficulty  is  not  wholly  obviated  by  placing  a  strainer 
across  the  mouth  of  the  bulb  to  prevent  the  fragments  from 
entering  it,  as  has  been  done  in  some  other  evacuators.  Let 
me  mention  in  this  connection  the  results  of  a  former  experi- 
ment. It  might  be  supposed  that  if  the  passing  fragments 
were  arrested  by  a  flat  strainer  placed  across  the  current, 
whether  at  the  orifice  of  the  bulb  or  elsewhere,  they  would 

^  Lancet,  January  7,  1882. 

2  Lancet,  September  24,  1881,  Fig.  5.  (See  pp.  300,  301,  of  this  volume.) 


A   SIMPLIFIED   EVACUATOR.  339 

,  fall  into  a  glass  receiver  placed  directly  below  them ;  but  this 
is  not  the  case.  Though  a  large  part  will  fall  into  it,  others 
collect  upon  the  strainer ;  and  unless  the  operator  pauses 
after  each  aspiration  till  they  have  settled  quietly  into  the 
receiver,  they  are  liable  to  be  carried  back  by  the  current, 
unless  it  is  a  very  feeble  one.  This  has  happened,  in  my 
own  experience,  whether  the  strainer  was  horizontal,  vertical, 
or  oblique.  The  fragments  do  not  glance  from  it  down  into 
the  receiver,  but  some  of  them  cling  to  it  until  the  current  is 
reversed,  and  then  go  back.  To  make  a  strainer  act  as  a 
trap,  the  fragments  should  pass  freely  beyond  it  and  be  in- 
tercepted only  on  their  return.  They  will  then  be  strained 
away  from  the  bladder  and  not  toward  it.  It  is  very  desir- 
able that  the  current  should  be  obstructed  while  the  bulb  is  ex- 
panding, whether  by  a  strainer  or  by  curves  and  angles  in  the 
tubes.  A  simple  flat  strainer,  placed  anywhere  across  the 
whole  current,  retards  it,  especially  if  the  urine  is  flocculent. 

I  find  that  the  simplest  expedient  for  collecting  the  frag- 
ments so  that  they  will  settle  undisturbed  into  the  glass  re- 
ceiver, is  to  admit  them  into  the  bulb  and  prevent  their  escape 
from  it.  After  many  experiments,  I  have  found  nothing  more 
effectual  for  this  purpose  than  a  straight  cylinder  with  per- 
forated walls,  which  is  practically  a  prolongation  of  the  cath- 
eter into  the  bulb.  The  water  after  bringing  the  fragments 
from  the  bladder  is  strained  as  it  returns.  To  the  open  end 
of  this  perforated  cylinder  a  valve  might  be  attached, — 
either  a  ball-valve  moving  loosely,^  which  is  less  liable  to 
obstruction  than  a  valve  with  a  hinge ;  or  still  better,  half  an 
inch  of  cotton  tube  at  the  same  point,  which  opens,  allowing 
the  fragments  to  pass  up  through  it,  and  collapses  with  the 
reversed  current,  cutting  off  their  retreat,  the  water,  as  it  re- 
turns, passing  back  through  the  perforated  walls.  In  operat- 
ing with  this  arrangement  I  have  found  it  to  work  perfectly ; 

^  Lancet,  September  24,  1881.     (See  p.  298  of  this  volume.) 


340  A  SIMPLIFIED  EVACUATOR. 

but  a  valve  is  not  necessary,  and  the  apparatus  is  more 
simple  without  it.^ 

The  evacuator  described  below  is  less  complex  in  construc- 
tion and  aspirates  more  perfectly  than  any  I  have  used.  It 
is  shown  in  Fig.  2,  and  is  a  compact  modification  of  one  for- 
merly published  in  the  "  Lancet "  2  as  "  a  simplified  evacua- 
tor," but  without  the  stand  of  that  instrument,  which  is 
not  essential,  and  has  been  omitted  because  operators  seem 
to  prefer  to  do    without  it. 

The  catheter  is  made  to  enter  a  spherical^  bulb  obliquely 
upward,  and  is  prolonged  to  the  centre  of  the  cavity  by  the 
tube  just  referred  to,  open  at  its  end  and  perforated  on  its 
sides  with  numerous  holes,  which  act  as  a  strainer.  The 
catheter,  tube,  and  elastic  bulb  are  in  a  straight  line.  This 
arrangement  has  the  great  advantage  of  not  deflecting  the 
current  and  thereby  diminishing  its  force.  During  aspiration 
the  current  bearing  the  debris  is  drawn  straight  from  the 
bladder  through  the  tube,  into  the  widest  part  of  the  bulb, 
and  the  fragments,  spreading  there,  fall  toward  the  receiver. 
But  when  the  bulb  is  compressed,  the  water  returns  mostly 
through  the  perforations  in  the  side  of  the  tube,  because  their 
area  is  collectively  larger  than  the  opening  at  the  end  of  it, 

1  A  hinged  or  other  valve  strainer  at  the  mouth  of  the  catheter,  if  it 
opens  to  allow  the  water  and  the  debris  to  pass  through,  works  well 
enough  as  a  substitute  for  the  tube-strainer.  The  catheter  then  opens 
directly  into  the  bulb,  and  the  route  is  the  shortest  possible  one.  But 
the  tube-strainer  is  much  more  simple,  and  the  two  inches  which  it  adds 
to  the  length  of  the  catheter  are  quite  unimportant.  In  fact  the  usual 
length  of  the  catheter  itself  might  be  reduced  two  inches  to  shorten  the 
route  if  desired.  For  strainers  and  strainer  traps,  see  "  Lancet,"  September 
24,  1881.  (See  pp.  298,  301,  of  this  volume.)  As  there  described,  they  are 
used  in  pairs,  —  one  protecting  the  entrance  of  the  bulb,  while  the  other, 
furnished  with  a  valve  and  placed  at  the  head  of  the  catheter,  acts  as  a 
trap.  The  former,  for  reasons  already  given,  is  not  always  advantageous ; 
but  an  effectual  catheter-trap  to  arrest  returning  fragments  is  necessary. 

2  Lancet,  September  24,  1881,  Figs.  8  and  11.  (See  pp.  304,  806,  of 
this  volume.) 


A  SIMPLIFIED  EVACUATOR. 


341 


and  because  they  are  nearer  the  point  at  which  the  water 
passes  out  of  the  bulb.  By  means  of  this  simple  contrivance 
the  water  is  strained,  and  the  return  of  fragments  is  practi- 
cally prevented.  The  tube-strainer  can  be  removed,  cleaned, 
and  replaced  in  a  moment ; 
and  this  is  an  advantage 
when  there  is  much  mucus, 
coagulum,  or  shreddy  ma- 
terial in  the  urine  by  which 
the  holes  of  any  strainer 
may  be  partly  obstructed. 
Even  then  this  tube  contin- 
ues to  work  well ;  but  it  is 
better  to  pass  a  brush  over 
it  if  mucus  adheres  to  it. 
It  can  be  examined  as  often 
as  the  receiver  is  emptied. 
After  the  water  has  once 
been  changed,  less  mucus 
will  be  found. 

The  action  of  the  per- 
forated tube  meets  all  re- 
quirements. In  fact,  if  the 
catheter  is  prolonged  into 

the  bulb  by  a  tube  which  has  no  perforations  in  its  sides,  the 
instrument  will  perform  very  fairly.  Such  a  tube  might  be 
fastened  permanently  in  the  bulb ;  but  the  apparatus  can  be 
kept  cleaner  if  there  is  a  joint  through  which  it  can  be 
removed.  The  cavity  of  the  bulb  cannot  be  made  too 
accessible. 

1  The  writer's  Evacuator.  It  has  an  elastic  bulb,  glass  receiver,  and 
stop-cocks.  Below,  there  is  a  metal  brace  between  the  collar  of  the 
glass  receiver  and  that  of  the  catheter  to  steady  the  latter.  Within  the 
bulb,  and  open  at  the  end,  is  a  tube  strainer  to  prevent  the  return  of 
debris.     The  bulb  forms  a  concentric  handle  to  the  catheter. 


Fig.  2.1 


342  A  SIMPLIFIED  EVACUATOR. 

The  above  arrangement  has  several  other  advantages. 

1.  With  the  trap  placed  inside  the  bulb,  the  instrument  is 
more  compact,  shorter,  and  more  easily  held  ;  and  as  the 
spherical  bulb  is  here  placed  in  a  straight  line  with  the 
catheter,  it  forms  a  concentric  handle,  which  enables  the 
surgeon  to  direct  the  catheter  better  than  when  this  handle 
is  placed  above  it,  at  an  angle  with  it. 

2.  The  glass  receiver  is  here  attached  immediately  below 
the  bulb,  and  is  easily  seen.  A  glass  cylinder  shows  frag- 
ments better  than  a  globe,  but  is  less  capacious. 

3.  It  is  well  known  that  the  bulb  in  action,  especially  when 
placed  above  the  catheter,  at  an  angle  with  it,  communicates 
an  oscillation  to  the  latter,  of  which  some  patients  complain. 
By  a  special  device,  the  catheter  is  here  made  so  steady  while 
the  instrument  is  in  use  that  a  separate  stand  is  not  needed. 
This  consists  of  a  brace  uniting  the  metal  collar  of  the 
catheter  with  that  of  the  glass  receiver,  and  so  steadying  it 
that  the  catheter  no  longer  feels  the  movement  of  the  bulb.  The 
conical  projection  of  the  bulb  at  the  point  where  the  catheter 
is  attached  contributes  to  the  same  result. 

4.  An  elastic  hose  (Fig.  3)  which  can  be  quickly  connected 
with  the  top  of  the  bulb  facilitates  the  operation.  We  can 
then,  with  a  single  compression  of  the  bulb,  get  rid  of  any 
air  or  discolored  water,  and  replace  it  with  clean  water  with- 
out delay  and  without  uncoupling  the  catheter.  Besides,  no 
matter  how  the  bulb  may  have  been  filled  at  first,^  it  is  better 
to  be  able  to  vary  the  quantity  of  water  at  any  moment  after- 
ward ;  and  although  without  a  hose  we  can  add  water  through 
a  tunnel,  we  cannot  as  easily  withdraw  it  in  the  same  way. 
We  should  be  able  to  regulate  the  amount  of  water  carefully, 
not  only  at  the  outset,  according  to  the  capacity  of  the  par- 

1  We  can  quickly  fill  the  evacuator  from  a  pitcher,  if  we  invert  the 
bulb  and  detach  the  receiver.  The  little  remaining  air  can  afterward 
be  made  to  escape  through  the  hose  or  tunnel. 


A   SIMPLIFIED  EVACUATOR. 


343 


ticular  bladder,  but  also  during  the  operation.  For  example, 
it  is  sometimes  desirable  to  draw  it  quickly  away  to  allow 
for  the  muscular  strain  of  retching,  or  to  relieve  the  expul- 
sive efforts  of  the  bladder,  which  sometimes  becomes  very 
tense,  and  ejects  water  at  the  side  of  the  catheter,  even  of 


CODMAN  &  SHURTLEFF, 
BOSTON. 


Fig.  31 


the  large  ones.  More  water  is  required  at  first,  while  frag- 
ments are  numerous,  to  separate  them  and  prevent  their  be- 
ing wedged  in  entering  the  catheter.  Later  in  the  operation, 
less  water  makes  it  easier  to  find  the  last  fragment,  the 
minimum  being  reached  when  the  wall  of  the  bladder  vibrates 
against  the  orifice  of  the  catheter  as  the  bulb  expands,  pain- 
fully so  if  the  patient  is  conscious.  It  is  then  important  to 
add  water  again,  just  enough  to  prevent  this  obstruction  and 
no  more.  In  short,  there  is  no  doubt  that  we  can  evacuate 
better  by  trying  a  little  more  or  a  little  less  water  from  time 
to  time  during  the  operation,  and  that  this  can  be  done  more 

1  Apparatus  belonging  to  the  evacuator  but  not  essential  to  it ;  namely, 
a  tunnel  and  a  hose,  both  of  which  fit  on  to  the  top  of  the  bulb,  and 
an  extra  stop-cock  for  the  evacuating  catheter. 


344  A  SIMPLIFIED  EVACUATOR. 

accurately  and  more  readily  by  means  of  a  hose  than  in  any 
other  way.  With  one  end  attached  to  the  bulb,  the  other  can 
conveniently  remain  in  a  vessel  placed  between  the  patient's 
knees,  or  in  any  convenient  position,  or  remain  unattached 
till  wanted. 

The  hose  may  be  used  or  not.  For  those  who  prefer  a 
tunnel  (Fig.  3),  one  is  furnished  with  the  instrument ;  as  also 
a  second  stop-cock  (Fig.  3),  which  I  find  useful  if  attached 
to  the  head  of  the  catheter,  in  keeping  the  bed-clothes  dry 
when  the  bulb  is  to  be  removed. 


INDEX. 


INDEX. 


PART  I.  —  DISLOCATIONS   OF  THE  HIP. 


A. 

Abduction,  34. 

Abstract,  4. 

Acetabulum,   unchanged  in   old  luxar 
tion,  101. 

fracture  of  rim  of,  109. 

head  of  femur  driven  through.  111. 

asserted  fracture  of,  112. 
Amblard,  case  of  perineal  luxation,  73. 
Anaesthesia  in  reduction,  30. 

by  wine,  30. 
Angular  extension,  114. 

apparatus  for,  114,  116. 

useful  in  old  luxations,  102. 
Annandale,  reduction  of  pubic  disloca- 
tion, 87. 
Arthritis,  dry  chronic,  after  dislocation, 

52. 
Aubry,  autopsy  of  pubic  dislocation,  81. 

reduction  of  pubic  dislocation,  85. 


B. 


Beraud,  case  of  fractured  acetabulum, 
111. 

Bertin,  ligament  of,  16. 

Bidard,  two  autopsies  of  dislocation 
below  the  tendon,  58. 

Bouisson,  case  of  dislocation  on  the 
tuberosity  with  slight  flexion,  72. 

Boyer,  on  resistance  of  capsular  liga- 
ment, 14. 

Broca,  M.,  102. 

Brodhurst,  B.  E.,  resistance  to  reduc- 
tion not  capsular,  1 01 . 


Brodie,  fracture  of  socket  inferred,  1*2. 

Buck,  reduction  of  thyroid  dislocation, 
76. 

Busch,  W.,  resistance  to  reduction  liga- 
mentous and  capsular,  14. 


C. 


Cabot,  case  of  reduction  by  rotation,  52. 
Cadge,  N.,  autopsy  of  supra-spinous  dis- 
location, 91. 
Callender,  G.  W.,  capsule  no  obstacle 

to  reduction,  49. 
Capsular  orifice  to  be  enlarged,  32. 

case  of  enlargement  of,  53. 
Capsule  of  the  hip,  20. 

its  condition  in  autopsies  of  disloca- 
tions, 10,  16. 
Chapplain,  on  superficial  and  deep  iliac 

luxations,  43. 
Chassaiguac,    resistance    to    reduction 

purely  muscular,  13. 
Circumduction,  varieties  of,  35,  50,  52, 

119,  132. 
Cock,  his  rule  for  reduction,  47. 
Collin,  reduction  of  dorsal  dislocation, 

46. 

Colombot,  his  method  of  reduction,  46. 

Cooper,  Sir  Astley,  cases  of  reduction 

by  pulleys,  11,  12. 

resistance  to  reduction  muscular,  12. 

his  erroneous  method  of  reduction, 

27. 
case  of  dislocation  below  tendon,  61. 
case  of  dislocation  near  tuberosity, 
71. 


348 


INDEX. 


Cooper,  Sir  Astley  (continued). 

case  of  thyroid  dislocation  reduced 
by  extension  in  sitting  posture, 
78. 
cases  of  fractured  acetabulum,  110, 

111. 
Bransby,  autopsy  of  pubic  disloca- 
tion, 81. 
Cummins,  case  of  supra-spinous  disloca- 
tion, 90. 


D. 


Despres,  his  method  of  reduction,  64. 
Devilliers,  reduction  of  pubic   disloca- 
tion, 85. 
Dislocation,  regular,  4,  26,  35. 
in  dead  subject,  9. 
cause  of  difficulty  in  reducing,  13. 
confinement  of  limb  in  final  position 

of  reduction  of,  31,  53,  105,  109. 
partial,  24. 
varieties  of,  24. 

dorsal,  varieties  of,  between  the  ro- 
tator muscles,  35,  42. 
unimportant  in  reduction 

by  flexion,  37. 
mutually  convertible,  37. 
signs  of,  37. 
inversion  in,  38. 
autopsy  of,  38. 
congenital,  38. 
shortening  in,  40. 
apparent,  39. 

limited  by  Y  ligament,  39. 
mobility  in,  41. 
differential  diagnosis  in,  41. 
apparent  reduction  of,  41. 
reduction  of,  by  traction,  45. 

by  rotation,  48. 
lateral  swing   of    femur   how 

hindered  in,  48. 
above   the   obturator,    how  to 

reduce,  49. 
depression  of  pelvis  in  reduc- 
tion of,  50. 
reproduced  after  reduction,  53. 
how   to  prevent   reproduction 

of,  53. 
muscles  subcutaneously  divided 
in,  54. 


Dislocation  (continued). 

dorsal,  case  of,  at  3|  years,  55. 
below  tendon,  56. 

why  so  called,  57. 
Cooper's  case,  57. 
Malgaigne's  case,  58. 
autopsies  of,  58. 
identified   in    living    sub- 
jects, 65. 
signs  of,  59. 
mechanism  of,  61. 
reduction  of,  64. 
reproduced  by  sitting  up, 
58,  59. 
on  "  ischiatic  notch,"  not  worthy  of 
the  name,  56. 
erroneously  supposed  irreduci- 
ble, 56. 
alleged  difficulty  of  reducing, 

57. 
Cooper's  case,  57,  130. 
thyroid  and  downward,  66. 
thyroid,  reduction  of,  75. 
downward,  reduction  of,  79. 

readily  converted  into   others, 
66. 
vertical  downward,  66,  69. 
on  tuberosity,  66. 
perineal,  66,  71. 

autopsy  of,  71. 
on  the  pubes,  80. 

autopsy  of,  81,  91. 
reduction  of,  85. 
sub-spiuous,  82,  86. 
supra-spinous,  90. 
anterior  oblique,  87. 
posterior  oblique,  93. 
everted  dorsal,  94. 

reduction  of,  96. 
irregular,  4,  26,  97. 

Y  ligament  wholly  broken  in, 

4,  26,  97. 
positions  of  femur  in,  97,  98. 
upward,  99. 
downward,  100. 
reduction  of,  101. 
old,  reduction  of,  101. 
from  hip  disease,  104. 
with  fracture  of  femur,  105. 
spontaneous,  105. 


INDEX. 


349 


E. 


Extension,  straight,  by  pulleys,  obso- 
lete, 117,  123. 

r. 

Flexion,  34. 

Flexion  method  of  reduction,  28. 
Fountain,  E.  J.,  two  cases  of  pubic  dis- 
location reduced  by  manipulation,  85. 
Fournier,  case  of  acetabulum  unchanged 

in  old  dislocation,  102. 
Fracture  of  neck  of  femur,  6,  22,  34. 
from  manipulation,  34. 
better  than  unreduced  disloca- 
tion, 102. 
of  shaft  of  femur,  with  dislocation, 

105. 
of  pelvis,  108. 

simulating  dislocation,  113. 


G. 


Gay,  case  of  fractured  acetabulum,  141. 

Gelle  on  capsular  slit,  32. 

Gely,  case  of  sub-spinous  dislocation,  83. 

Gordon,  case  of  everted  dorsal  disloca- 
tion, 95. 

Graves,  case  of  fracture  of  femoral  neck 
during  reduction,  102. 

Guersant,  on  superficial  and  deep  iliac 
luxations,  43. 

Gunn,  capsular  ligament  capable  of  pro- 
ducing the  signs  of  luxation,  14. 
route  of  bone  in  reduction,  32. 

Gurney,  cases  of  dislocation  downward, 
69. 

H. 

Hamilton,  F.  H.,  on  fractures  and  dis- 
locations, 41. 
cases   of    spontaneous   dislocation, 
106. 
Harlow,  E.  A.  W.,  case  of  dorsal  dislo- 
cation, 50. 
Hayward,  G.,  case  of   deformity  from 

arthritis,  52. 
Head  of  femur,  excision  of,  104. 

driven  through  acetabulum.  111. 
Hip  disease,  with  dislocation,  104. 

after  reduction  of  dislocation,  105. 


Hippocrates,  on  flexion  method,  27. 
on  shaking  the  limb  in  reduction, 

27. 
on  dislocation  downward,  70. 


I. 


Iliac  luxation,  on  change  of,  to  ischiatic, 

63. 
Immobility  of  thigh,  its  indications,  49. 
Irregular  dislocations,  4,  26,  97. 
Irvine,  J.  M.,  case  of  pubic  dislocation 

reduced,  87. 
Ischiatic  notch,  prejudice  against,  43, 56. 
femur  never  slips  into,  56. 
dislocations  into,  erroneously   sup- 
posed irreducible,  56. 
easier  than  dorsal  to  reduce, 

102. 
changed  to  iliac,  63. 


J. 


Jerk,  upward,  in  reduction,  48. 

Jones,  semi-flexed  thigh  in  reduction,  49. 


K. 


Keate,  case  of  dislocation  on  tuberos- 
ity, 74. 
case  of  fracture  of  socket  inferred 
in,  100,  112. 


Langmaid,  case  of  spontaneous  disloca- 
tion, 106. 
Larrey,  his  method  of  reduction,  78. 
case  of  pubic  dislocation  at  a  riglit 

angle,  81. 
case   of  pubic  dislocation  reduced 
by,  87. 
Lendrick,  case  of  head  of  femur  driven 

through  acetabulum,  112. 
Lente,  case   illustrating  mechanism  of 

supra-spinous  luxation,  94. 
Ligamentum  teres,  20. 
Limb,  confinement  of,  as  reduced,  31, 
53,  103,  109. 
how  to  be  held  in  reduction,  32, 
Lisfranc,  case  of  reduction  of  disloca- 
tion below  tendon,  64. 


350 


INDEX. 


Luke,  case  of  thyroid  dislocation,  72. 
Lyman,  G.  H.,  case  of  spontaneous  dis- 
location, 107. 


M. 


Maisonneuve,  fracture  of  acetabulum, 
110. 
union  of  broken  acetabulum,  111. 
Malespiue,  account  of   Lisfranc's   case 
of  reduction  by  Despre's's  method,  64. 
Malgaigue,  route  of  bone  in  reduction, 
32. 
on  ischiatic  and  iliac  luxation,  63. 
Mann,  B.,  case  of  dorsal  dislocation  re- 
duced by  depressing  pelvis,  51. 
Markoe,  semi-flexed  thigh  in  reduction 
of  dorsal  dislocation,  31. 
cases  of  thyroid  luxation  reduced 
by  rotation,  76. 
Mobility,  degree  of,  an  important  sign 

in  dorsal  dislocation,  41. 
Moore,  E.  M ,  case  of  spontaneous  dis- 
location, 107. 
case    of    head    of    femur    driven 
through  acetabulum.  111. 
Morel-Lavalle'e,  case  of  head  of  femur 

driven  through  acetabulum,  112. 
Morgan,  case  of  everted  dorsal  disloca- 
tion, 96. 
Muscles,  their  action  in  dislocation,  1.5, 
23. 
subcutaneous  division  of,  54,  55. 

N. 

Nunneley,  incomplete  anaesthesia  to  be 
preferred  in  reduction,  30. 
reduction  of   ischiatic  luxation  by 
manipulation,  difficult,  64. 


0. 


Oblique  extension,  117. 
Obturator  internus  muscle,  21. 
source  of  its  strength,  21. 
its  importance  in   fracture   of   the 

femoral  neck,  22. 
its  normal  position,  61. 
its  position  in  dislocation  below  the 
tendon,  61. 


Old  dislocations,  101. 
Cooper's  case,  101. 

Oldknow,  case  of  anterior  oblique  luxa- 
tion, 89. 

OUivier,  case  of  dislocation  below  the 
tendon,  59. 

Oscillation  in  reduction,  29. 


Papers,  author's,  on  dislocation,  10. 

Parea,  Annibal,  his  method   of   reduc- 
tion, 48. 

Parker,  W.,  case  of  perineal  luxation,  73. 

Parmentier,  case  of   luxation   between 
pyriformis  and  obtixrator  internus,  43. 

Pelvis,  fracture  of,  113. 

often    inferred    without    adequate 
proof,  112. 

Perineal  luxation,  case  of,  with  autopsy, 
71. 

Pope,  case  of  perineal  luxation,  73. 

Position  of  patient  and  surgeon,  30. 

Pouteau,  on   disadvantage   of  straight 
extension,  114. 

Q. 

Queen,  case  of  sciatic  nerve  engaged  on 
femoral  neck,  58. 

E. 

Reduction,  general  remarks  on,  26. 

cases  of,  where  limb  requires  to  be 
confined,  31,  109. 
Regular  dislocations,  4,  26,  35. 
Reid,  W.  W.,  muscles  the  chief  source 
of  resistance  in  reduction,  14. 
his  method  of  reduction,  29. 
anaesthesia  a  detriment  to  reduc- 
tion, 30. 
incision  in  capsule,  33. 
Richet,  case  of  fractured  acetabulum, 

111. 
Ridge,  intertrochanteric,  7. 
Rim  of  acetabulum,  fracture  of,  109. 
Rotation,  28. 

explained,  34. 
Rotator  muscles,  their  breaking  weights, 

21. 
Roux,  case  of  thyroid  luxation,  68. 


INDEX. 


351 


Sciatic  uerve  engaged  on  femoral  neck, 
44,  58. 

Servier,  case  of  dislocation  above  the 
pyrifonuis,  43. 

Shrady,  case  of  everted  dorsal  disloca- 
tion, 96. 

Smith,  N.  R.,  muscles  the  chief  agents 
in  dislocation  and  reduction,  13. 
his  method  of  reduction,  29. 

Sophocles,  Prof.,  signification  of  a  term 
in  Hippocrates,  27. 

Spontaneous  dislocation,  106. 

Square,  W.  J.,  case  of  dorsal  dislocation 
reduced  by  flexion,  47. 

Stanski,  case  of  dislocation  near  tuber- 
osity, 72,  73. 
specimen  of  anterior  capsule  ossi- 
fied, 74. 

Struthers,  on  the  ligamentum  teres,  20. 

Sub-spinous  dislocation,  80,  82. 

Supra-spinous  dislocation,  90. 
reduction  of,  96. 

Surgeon  to  have  definite  plan  of  reduc- 
tion, 29. 

Sutton,  G.,  method  of  reduction,  47. 

Swing,  lateral,  of   femur,  hindered  by 
capsular  attachments,  48. 

Syme,  James,  on  dislocation  on  dorsum 
and  ischiatic  notch,  43. 

Symes,  G.  E,.,  case   of  everted   dorsal 
dislocation,  95. 


Theory,  author's,  15. 

Thomas,  case  of  dorsal  dislocation,  52. 

Thyroid  dislocation,  signs  of,  67. 

case  of,  in   child  six   months  old, 
67. 
TiUaux,  on  capsular  resistance  in  dor- 
sal dislocation,  63. 


Traction,  28. 

Travers,  case  of  fracture  in  reduction  of 

ischiatic  luxation  by  pulleys,  64. 

case  of  supra-spinous  dislocation,  91. 

Tyer,  M.,  cases  of  fractured  acetabulum, 

110. 


Van  Buren,  W.  H.,  case  of  everted  dor- 
sal dislocation,  96. 
Verueuil,  case  of  fracture  in  reducing 
pubic  dislocation,  34. 
case  of  dislocation  reproduced  by 
sitting  up,  58. 
Vertu,  case   of  thyroid  dislocation  re- 
duced by  flexion,  77. 

W. 

Weber,  G.  and  E.,  on  the  Y  ligament,  1 9. 
Weitbrecht,  J.,  on  the  Y  ligament,  19. 
Wiuslow,  J.  B.,  on  the  Y  ligament,  18. 
Wormald,  case  of  irreducible  dislocation 
on  ischiatic  notch,  43. 
case    of    dislocation    towards    the 

tuberosity,  59. 
case  of  sub-spinous  dislocation,  84. 


Y. 


Y  ligament,  description  of  the,  16. 
its  fasciculi,  17. 
its  breaking  weight,  18. 
its  great  strength,  18,  19. 
to  be  tightened  in  certain  cases  of 

reduction,  31. 
its  external  band  produces  inversion 
in  dorsal  dislocation,  37. 
ruptured  in  supra-spinous  dis- 
location, 90. 
ruptured  in  everted  dorsal  dis- 
location, 94. 


352 


INDEX. 


FRACTURES  OF   THE  HIP. 


Anatomical  structure  of  the  neck  of  the 
femur,  141,  158,  161,  178. 
Merkel  on  the,  159. 
Meyer,  159. 

pathological  results  due  to  the,  142. 
rotation,  142. 
shortening,  142,  179. 
Wyman,  on  the,  159. 


B. 


Bony  union  of   "  intra-capsular "  frac- 
ture, 140,  145,  150,  183. 
impacted  fracture  near  the   head, 
140,  145,  150,  183. 


Comminuted  fracture  of  the  trochanters, 
■with  eversion,  154. 
with  inversion,  154,  184. 
without  impaction,  154,  172,  184. 
less  common  than  impacted,  1 54. 
Crack  in  the  neck  of  the  femur,  156. 
Crepitus,  181. 

Cushing,  case  of  impacted  fracture  near 
the  head,  152,  183. 


D. 

Diagnosis,  differential,  147. 


E. 


Eversion,  146,  1.54,  179,  180. 
Examination,   protracted,    is   unjustifi- 
able, 146,  185. 
Extension,  object  of,  141,  187. 


P. 


Femur,    anatomical    structure    of    its 
neck,  141,  158,  161,  178. 
false  joint  in  neck  of,  155. 
true  neck  of,  143,  158,  162. 
Fractures  of  the  neck  of  the  femur,  6, 
22,34,  118. 
anatomy  of,  144,  160,  178,  179. 
characteristics  of,  139. 
classification  of,  145,  154,  175. 
comminuted,  of  the  trochanters,  172. 
with  eversion,  154. 
with  inversion,  155. 
without  impaction,  154,  184. 
crepitus  in,  181. 
danger  in  manipulating,  154,  168, 

174,  185. 
frequency  of,  139,  175,  177. 
"  within  "  and  "  without  "  the  cap- 
sular ligament,  145, 150,  172, 
176. 
distinction  difficult,  145. 
unimportant,  145. 


G. 


Gay,  case  of  impacted  fracture  near  head 
of  femur,  150,  151,  182. 


H. 


Hamilton,  impacted   fracture  with   in- 
version, 146,  147. 


Impacted  fractures,  anatomy  of,  144. 
common,  139,  175,  177. 
eversion  in,  142. 

identification  of ,  essential,  140,  177, 
181. 


INDEX. 


353 


Impacted  fractures  (continued). 
importance  of,  140. 
iujury  from   over  examination    of, 

154,  168,  174,  182. 
near  the  head  of  the  femur,  146, 150, 

170,  182. 
of  the  base  of  the  neck,  with  ever- 
sion,  139,  167,  177. 
with  inversion,  146,  147,  172. 
of  the  small  part  of  the  cervix,  146, 
172,  176. 
common  •  in    elderly    persons, 

172,  175. 
prognosis  unfavorable, 176. 
resulting  in  false  joint,  155. 
of  neck  into  head,  146. 
shortening    in,    142,  155,  179. 
signs  of,  140. 
Impaction  explained,  179. 
Intertrochanteric  ridge,  143,  144. 
Inversion  explained,  142,  147,  155,  180. 


Joint,  false,  155. 


M. 


Manipulation,  protracted,  unjustifiable, 

146,  154,  168,  174,  182,  185. 
Merkel,  on  the  structure  of  the  neck  of 

the  femur,  159. 
Meyer,  159. 
Mutual  impaction  of  head  and  neck,  1 52. 

N. 
Neck  of  femur,  true,  143,  158,  162. 


Object  of  extension  in  treatment,  141, 
147,  187. 


P. 


Pathology  of  neck  of  femur,  167. 
Prognosis  of  fractures  of  the  hip,  174, 
176. 
generally  favorable,  140. 


R. 

Robert,  on  posterior  impaction,  142. 
Rotation  in  impacted  fractures,  142. 


S. 


Shortening,  mechanism  of,  142,  179. 
Signs  of  fracture  of  the  hip,  140,  146, 

168. 
Smith,  R.  W.,  impacted  fracture  with 
inversion,  147,  149. 
comminuted   fracture    with   inver- 
sion, 155. 


Treatment  of  fractures  of  the  hip,  147, 

173,  185,  186. 
Trochanter,   comminuted   fracture    of, 

154. 
True  neck  of  the  femur,  143,  158,  162. 
pathology  of,  167. 

U. 

Unimpacted  fractures,  172. 
signs  of,  146. 

W. 

Wyman,  on  structure  of  the  neck  of  the 

femur,  159. 
Wolff,  159. 


28 


354 


INDEX. 


PART   II. —RAPID   LITHOTRITY. 


A. 

Adherent  stone,  219. 
Anaesthesia  in  lithotrity,  199,  296. 
Artificial  bladder,  206. 
Aspirator.     See  Evacuator. 

B. 

Bladder,  artificial,  206. 
capacity  of,  200,  237. 
casts  of,  216. 
cystitis  of,  320. 
damage  to,  by  angular   fragments, 

193,  265. 
injury   to,   by   lithotrite,    194,  214, 

321. 
interior  view  of,  215. 
over-distension  of,  200,  235,  238. 
how  to  avoid,  200,  237. 
position  of  bulb  affects  the,  235. 
removal  of  air  from,  273,  320. 
shape  of,  216,  218. 

modifications  in,  218. 
tolerance  of,  193,  221,  265,  296,  324. 
Bulb.     See  Evacuator. 


Clover's  apparatus,  196,  202,  243,  281. 
Connection,  elastic,  between  evacuator 

and  evacuating  tube,  276,  284. 
Cramptou's  apparatus,  196. 
Cystitis,  320. 


D. 


Divulsor  for  stricture,  294. 
Duration  of   sittings  in  old  operation, 
194,  214,  246,  296. 
in  new,  194,  214,  246,  261. 


E. 


Elastic  bulb.     .SVe  Evacuator. 

connection  between  evacuator  and 
evacuating  tube,  276,  284. 
Evacuating   instruments,  antiquity    of, 
196. 
old,  valueless,  195,  243. 
varieties  of,  196. 
sound,  299,  315. 

tubes,  advantages  of,  232,  236,  325. 
calibre  of,  202,  232,  283. 
curved,  270,  275,  322,  325. 
how  to  ])ass,  196,  236,  270,  280. 
large,  absolutely  essential,  201, 

232,  263,  275,  297. 
obstruction    in,   238,  272,  321, 
325. 
recognition  of,  208,  209. 
removal  of,  208,  238,  321. 
straight,  236,  270,  322,  325. 
easiest   to  introduce,  197, 
236,  270. 
Evacuation,  position  of  operator  during, 
199,  206. 
process  of,  204,  205,  248,  272,  276, 

279,  323. 
prevention  of   the  return  of   frag- 
ments, 301,  304,  326,  335. 
quantity  of   water  to  be   used   in, 
204,  271. 
Evacuator,  air  in,  removal  of,  278,  320. 
air  space  in,  278. 
details   of   construction,   268,    275, 

297,  322,  333. 
hose   attachment  of,  278,  283,  299, 

329,  342. 
improved,  274. 
manipulation  of,  204,  205,  237,  248, 

315. 
receiver  of,  for  fragments,  301,  326. 


INDEX. 


355 


Evacuator  (continued). 

simplified,  306,  332,  342. 
Sir  H.  Thompson's,  280,  336. 
stand  for,  269,  283,  302,  327. 
strainer  in,  298,  301,  304,  328,  330, 

340. 
trap  in,  301,  326,  339. 
used  as  a  sound,  299,  315. 
valve  in,  29,  301. 


Fatal  cases  of  litholapaxy,   222,   233, 

317. 
Fergusson's  operation,  310. 


H. 


Handerson's  catheter  scale,  256. 
Harmlessuess  of  long  sittings,  232,  318. 
Hose,  205,  278,  283,  299,  329,  342. 
How  to  pass  the  triangular  ligament, 
197. 
pass  an  enlarged  prostate,  198. 
remove  obstruction  in  the  tube,  208, 
238,  321. 


L. 


Large  calculi,  241,  282. 

instruments,  introduction  of,  197. 
Litholapaxie,  prix  d'Argenteuil,  285. 
Litholapaxy,  adapted  to  large   calculi, 

215,  221,  241,  282. 
cases  of,  219,  228,  249,  261,  316. 
dangers  of,  192,  213,  317,  321. 
derivation  of  term,  228. 
experience   valuable   in,    194,  274, 

318. 
fatal  cases  of,  222,  233,  317. 
harmlessuess  of  long  sittings,  232, 

318. 
instead  of  lithotomy,  221,  233. 
in  the  female,  225. 
mortality  attending,  222,  225,  233, 

261,  274,  317. 
object  of,  226,  245. 
theory  of,  232,  235. 
time  required  in  operation  of,  194, 

226,  238,  249,  262,  280. 


Lithotrite,  blades  of,  212,  267,  310. 
non-impacting,  229,  311. 
triangular  notches  of,  213,  231,  311, 

314. 
description  of,  210,  229,  239. 
fracture  of,  258,  260. 
handle  of,  211,  268,  307. 
large,  231,  254,  260,  267,  309. 

advantages  of,  239,  252,  309. 
lock  of,  211,  232,  267,  307,  330. 
manipulation  of,  214,  239. 
passage  of,  199,  280,  314. 
province  of,  210. 
shoe  of,  212. 

modified  tip  of,  311,  313. 
protects  the  bladder,  213. 
the  new,  210,  239,  252,  254,  258, 306, 
313,  330. 
to  comminute,  not  to  pulverize, 
210,  215. 
importance  of,  210,  225. 
with   fenestrated  blades,  210,  229, 
266,  311. 
Lithotrity,  anaesthesia  in,  199,  296. 
Civiale's,  191,  296. 
compared  with  lithotomy,  224,  233, 

242,  317. 
limitations  of,  192,  224,  233,  246. 
modern,  194,  296,  324,  332. 
modification  in,  226. 
Sir  H.  Thompson's,  222,  242,  255. 
time  required  in  operation  of,  194, 

214,  246,  264,  296. 
traditions  of,  191. 

M. 

Male    blade    lock    of   lithotrite,    267, 

307. 
Meatus,  incision  of,  275,  320. 


O. 


Obstruction  in  the  evacuating  tube,  208, 
238,  271,  316,  321. 
at  the  external  meatus,  320. 
inner  meatus,  198,  261. 
triangular  ligament,  197. 
prostate,  198. 
Otis's  discovery,  201,  246,  265,  281,  309, 
332. 


356 


INDEX. 


Position  of  the  operator,  199. 
Preparatory  treatment,  316. 
Prostate,  obstacle  of,  198. 

R. 

Rapid  lithotrity.     See  Litholapaxy. 
Right  hand  lock  of  lithotrite,  253. 


S. 


Sir  H.  Thompson's  views,  242,  254. 
Sir  P.  Crampton's  aspirator,  196. 
Stone,  adherent,  219. 
Stricture  of  the  urethra,  222,  233,  293. 
Surgical  kidney,  316. 

T. 

Trap  to  intercept  returning  fragments, 

298,  303,  305,  326,  328,  334. 
Treatment,  preparatory,  316. 
after  operation,  273,  317. 
Triangular  ligament,  obstruction  at,  197. 


U. 

Urethra,  injury  to,  309,  317. 
measurement  of,  197,  309. 
size  of,  246. 
stricture  of,  222,  233,  293. 

divulsion  of,  233,  237,  293. 


V. 


Valve  in  evacuator,  29,  301. 


W. 


Water  in  bladder,  changed  or  regulated 
by  a  hose,  205,  278,  283,  342. 

to  be  injected  before  crushing,  200, 
209. 

tube  for  injecting,  212. 

quantity  needed,  204. 

retained  by  an  elastic  band,  201, 
238. 


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